United States Government Accountability Office
GAO
Report to the Committee on Veterans’
Affairs, House of Representatives
June 2011
VA HEALTH CARE
Actions Needed to
Prevent Sexual
Assaults and Other
Safety Incidents
GAO-11-530
June 2011
VA HEALTH CARE
Accountability • Integrity • Reliability
Actions Needed to Prevent Sexual Assaults and Other
Safety Incidents
Highlights of GAO-11-530, a report to the
Committee on Veterans’ Affairs, House of
Representatives
Why GAO Did This Study
What GAO Found
Changes in patient demographics
present unique challenges for VA in
providing safe environments for all
veterans treated in Department of
Veterans Affairs (VA) facilities. GAO
was asked to examine whether or not
sexual assault incidents are fully
reported and what factors may
contribute to any observed
underreporting, how facility staff
determine sexual assault-related risks
veterans may pose in residential and
inpatient mental health settings, and
precautions facilities take to prevent
sexual assaults and other safety
incidents.
GAO found that many of the nearly 300 sexual assault incidents reported to
the VA police were not reported to VA leadership officials and the VA OIG.
Specifically, for the four VISNs GAO spoke with, VISN and VA Central Office
officials did not receive reports of most sexual assault incidents reported to
the VA police. Also, nearly two-thirds of sexual assault incidents involving
rape allegations originating in VA facilities were not reported to the VA OIG,
as required by VA regulation. In addition, GAO identified several factors that
may contribute to the underreporting of sexual assault incidents including
unclear guidance and deficiencies in VA’s oversight.
GAO reviewed relevant laws, VA
policies, and sexual assault incident
documentation from January 2007
through July 2010 provided by VA
officials and the VA Office of the
Inspector General (OIG). In addition,
GAO visited and reviewed portions of
selected veterans’ medical records at
five judgmentally selected VA
medical facilities chosen to ensure
the residential and inpatient mental
health units at the facilities varied in
size and complexity. Finally, GAO
spoke with the four Veterans
Integrated Service Networks (VISN)
that oversee these VA medical
facilities.
What GAO Recommends
GAO recommends that VA improve
both the reporting and monitoring of
sexual assault incidents and the tools
used to identify risks and address
vulnerabilities at VA facilities. VA
concurred with GAO’s
recommendations and provided an
action plan to address them.
View GAO-11-530 or key components.
For more information, contact Randall B.
Williamson at (202) 512-7114 or
[email protected].
VA does not have risk assessment tools designed to examine sexual assaultrelated risks veterans may pose. Instead, VA staff at the residential programs
and inpatient mental health units GAO visited said they examine information
about veterans’ legal histories along with other personal information as part of
a multidisciplinary assessment process. VA clinicians reported that they
obtain legal history information directly from veterans, but these self-reported
data are not always complete or accurate. In reviewing selected veterans’
medical records, GAO found that complete legal history information was not
always documented. In addition, VA has not provided clear guidance on how
such legal history information should be collected or documented.
VA facilities GAO visited used a variety of precautions intended to prevent
sexual assaults and other safety incidents; however, GAO found some of these
measures were deficient, compromising facilities’ efforts to prevent sexual
assaults and other safety incidents. For example, facilities often used patientoriented precautions, such as placing electronic flags on high-risk veterans’
medical records or increasing staff observation of veterans who posed risks to
others. These VA facilities also used physical security precautions—such as
closed-circuit surveillance cameras to actively monitor units, locks and alarms
to secure key areas, and police assistance when incidents occurred. These
physical precautions were intended to prevent a broad range of safety
incidents, including sexual assaults, through monitoring patients and
activities, securing residential programs and inpatient mental health units, and
educating staff about security issues and ways to deal with them. However,
GAO found significant weaknesses in the implementation of these physical
security precautions at these VA facilities, including poor monitoring of
surveillance cameras, alarm system malfunctions, and the failure of alarms to
alert both VA police and clinical staff when triggered. Inadequate system
installation and testing procedures contributed to these weaknesses. Further,
facility officials at most of the locations GAO visited said the VA police were
understaffed. Such weaknesses could lead to delayed response times to
incidents and seriously erode efforts to prevent or mitigate sexual assaults
and other safety incidents.
United States Government Accountability Office
Contents
Letter
1
Background
Nearly 300 Sexual Assault Incidents Were Reported Since 2007
through One of Two VA Reporting Streams
Not All Sexual Assault Incidents Are Reported Due to Unclear
Guidance and Insufficient Oversight
Self-Reported Legal Histories Are Commonly Used to Inform
Clinicians of Sexual Assault-Related Risks, but Guidance on
Information Collection Is Limited
VA Residential and Inpatient Mental Health Settings Use a Variety
of Precautions to Prevent Sexual Assaults and Other Safety
Incidents, but Serious Weaknesses Were Observed at Selected
Facilities
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation
5
9
14
25
30
42
44
45
Appendix I
Scope and Methodology
48
Appendix II
Analysis of VA Police Reports of Sexual Assault
Incidents from January 2007 through July 2010
57
Comments from the Department of Veterans
Affairs
62
GAO Contact and Staff Acknowledgments
72
Appendix III
Appendix IV
Tables
Table 1: Number of Sexual Assault Incidents by Category Reported
to VA Police by Year, January 2007 through July 2010
Table 2: Sexual Assault Incidents Reported to Four Selected VISNs
and VHA Central Office Leadership, January 2007 through
July 2010
Page i
13
16
GAO-11-530 Safety in VA Medical Facilities
Table 3: Selected VA Medical Facility Definitions of Sexual Assault
for the Assessment and Management of Victims of Recent
Sexual Assault
Table 4: Physical Security Precautions in Residential Programs and
Inpatient Mental Health Units at Selected VA Medical
Facilities
Table 5: Weaknesses in Physical Security Precautions in
Residential Programs and Inpatient Mental Health Units at
Selected VA Medical Facilities
Table 6: Total Sexual Assault Incidents Alleging Rape by
Perpetrator and Victim Gender, January 2007 through July
2010
Table 7: Total Sexual Assault Incidents Alleging Rape by
Perpetrator and Victim Relationship to VA, January 2007
through July 2010
Table 8: Patient-on-Patient Assault Incidents and Patient-onEmployee Assault Incidents by Type of Sexual Assault
Incident, January 2007 through July 2010
19
33
38
59
60
61
Figures
Figure 1: VA Reporting Process for Sexual Assaults and Other
Safety Incidents
Figure 2: VHA Central Office Reporting Process for Sexual Assaults
and Other Safety Incidents
Figure 3: Number of Sexual Assault Incidents Reported to VA
Medical Facility Police by VISN, January 2007 through
July 2010
Page ii
10
22
58
GAO-11-530 Safety in VA Medical Facilities
Abbreviations
CWT/TR
DOD
MMPI
IOC
NARA
NCPS
OIG
OSLE
PTSD
RRTP
VA
VHA
VISN
compensated work therapy/transitional residence
Department of Defense
Minnesota Multiphasic Personality Inventory
Integrated Operations Center
National Archives and Records Administration
National Center for Patient Safety
Office of the Inspector General
Office of Security and Law Enforcement
post-traumatic stress disorder
residential rehabilitation treatment programs
Department of Veterans Affairs
Veterans Health Administration
Veterans Integrated Service Network
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GAO-11-530 Safety in VA Medical Facilities
United States Government Accountability Office
Washington, DC 20548
June 7, 2011
The Honorable Jeff Miller
Chairman
The Honorable Bob Filner
Ranking Member
Committee on Veterans’ Affairs
House of Representatives
The Department of Veterans Affairs (VA) has developed a number of
initiatives in recent years designed to increase veterans’ use of VA medical
facilities throughout the nation. These initiatives have targeted several
specific veteran populations—including women veterans, young veterans
from the military operations in Iraq and Afghanistan, and veterans facing
legal issues or those currently incarcerated. Such outreach initiatives have
increased the number of veterans from these specific populations
participating in residential and inpatient mental health care programs at
VA medical facilities and have changed the demographics of patients cared
for by VA.
Such changes in patient demographics along with the department’s
commitment to providing health care services to all eligible veterans
present unique challenges for VA both in providing and maintaining
accessible care and keeping veterans and staff safe in VA medical
facilities, including those that treat veterans suffering from mental health
conditions. During our recent work on services available for women
veterans in VA medical facilities, several clinicians raised concerns about
the safety of women veterans in mental health programs at one VA medical
facility. 1 For example, these clinicians raised concerns about the safety of
women veterans in a VA residential mental health facility that housed both
women veterans and veterans who had committed sexual crimes in the
past. Clinicians also expressed concerns about women veterans receiving
treatment in the inpatient mental health units of this VA medical facility
because they did not feel adequate safety precautions were in place to
protect women admitted to these units.
1
See GAO, VA Health Care: VA Has Taken Steps to Make Services Available to Women
Veterans, but Needs to Revise Key Policies and Improve Oversight Processes, GAO-10-287
(Washington D.C.: Mar. 31, 2010).
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GAO-11-530 Safety in VA Medical Facilities
These concerns highlight the importance of VA having both effective
security precautions in place at its medical facilities, especially those with
residential and inpatient mental health programs, and a consistent way to
exchange information and facilitate discussions about safety incidents,
,
including sexual assault incidents. 2 3 VA has policies in place regarding
security precautions in residential and inpatient mental health settings and
procedures for reporting and analyzing patient safety incidents through its
National Center for Patient Safety (NCPS). 4 For example, VA requires that
residential and inpatient mental health facilities conduct periodic reviews
of the security precautions in use in these settings. Also, VA’s NCPS has
established procedures for medical facilities to report patient safety
incidents that occur in these facilities to leadership officials.
You asked us to examine: (1) VA’s processes for reporting sexual assault
incidents and the volume of these incidents reported in recent years;
(2) the extent to which sexual assault incidents are fully reported and
what factors may contribute to any observed underreporting; (3) how
medical facility staff determine sexual assault-related risks veterans may
pose in residential and inpatient mental health settings; and (4) the
precautions in place in residential and inpatient mental health settings to
prevent sexual assaults and other safety incidents and any weaknesses in
these precautions.
To examine VA’s processes for reporting sexual assault incidents, the
volume of these incidents reported in recent years, the extent to which
these incidents were fully reported, and factors that may contribute to any
observed underreporting, we reviewed relevant VA and Veterans Health
2
In this report, we use the term safety incident to refer to intentionally unsafe acts—
including criminal and purposefully unsafe acts, clinician and staff alcohol or substance
abuse-related acts, and events involving alleged or suspected patient abuse of any kind.
These safety incidents are excluded from the reporting requirements outlined by the VA
National Center for Patient Safety (NCPS).
3
In this report, we use the term sexual assault incident to refer to suspected, alleged,
attempted, or confirmed cases of sexual assault. All reports of sexual assault incidents do
not necessarily lead to prosecution and conviction. This may be, for example, because an
assault did not actually take place or there was insufficient evidence to determine whether
an assault occurred.
4
NCPS manages VA’s overall patient safety reporting system and focuses its data collection
and oversight on adverse events that represent primarily unintentional medical mistakes,
such as errors in medication administration, patient falls, and wrong-site surgeries. The
collection of information on intentionally unsafe acts, including criminal acts such as
sexual assault, is specifically exempted from NCPS responsibility by VA policy.
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GAO-11-530 Safety in VA Medical Facilities
Administration (VHA) policies, handbooks, directives, and other guidance
documents on the reporting of safety incidents. 5 We also interviewed VA
and VHA Central Office officials involved with the reporting of safety
incidents—including officials with VA’s Office of Security and Law
Enforcement (OSLE), VHA’s Office of the Deputy Under Secretary for
Health for Operations and Management, and VHA’s Office of the Principal
Deputy Under Secretary for Health. 6 In addition, we conducted site visits
to five VA medical facilities. These judgmentally selected medical facilities
were chosen to ensure that our sample: (1) had both residential and
inpatient mental health settings; (2) reflected a variety of residential
mental health specialties, including military sexual trauma; (3) had
medical facilities with various levels of experience reporting sexual
assault incidents; and (4) varied in terms of size and complexity. 7 During
the site visits, we interviewed medical facility leadership officials and
residential and inpatient mental health unit managers and staff to discuss
their experiences with reporting sexual assault incidents. We also spoke
with officials from the four Veterans Integrated Service Networks (VISN)
responsible for managing the five selected medical facilities to discuss
their expectations, policies, and procedures for reporting sexual assault
incidents. 8 Information obtained from these VISNs and VA medical
facilities cannot be generalized to all VISNs and VA medical facilities. In
addition, we interviewed officials from the VA Office of the Inspector
General’s (OIG) Office of Investigations—Criminal Investigations
Division—to discuss information they receive from VA medical facilities
about sexual assault incidents that occur in these facilities. Finally, we
reviewed documentation of reported sexual assault incidents at VA
medical facilities provided by VA’s OSLE, the VA OIG, and VISNs from
5
Within VA, VHA is the organization responsible for providing health care to veterans at
medical facilities across the country.
6
We also spoke with officials from VHA’s Office of Mental Health Services and the Women
Veterans Health Strategic Health Care Group.
7
VA medical facilities were selected to ensure that at least one facility with no experience
reporting sexual assault incidents was included in our judgmental sample of facilities.
Other selected medical facilities all had some experience reporting sexual assault
incidents. To determine facilities’ histories of reporting sexual assault incidents, we
reviewed closed investigations conducted by the VA Office of the Inspector General (OIG)
Office of Investigations—Criminal Investigations Division. This selection allowed us to
ensure that a greater variety of perspectives on sexual assault incidents were captured
during our field work.
8
Two of the facilities we visited were located within the same VISN. VISNs are responsible
for the day-to-day management of facilities within their network.
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GAO-11-530 Safety in VA Medical Facilities
January 2007 through July 2010, to determine the number and types of
incidents reported, as well as which VA and VHA offices were notified of
those incidents. For this analysis, we used a definition of sexual assault
that was developed for the purpose of this report. 9 Our analysis of VA
police and VA OIG reports was limited to only those incidents that were
reported and cannot be used to project the volume of sexual assault
incident reports that may occur in future years. Following verification that
VA police and VA OIG incidents met our definition of sexual assault and
comparisons of sexual assault incidents reported by the two groups within
VA, we found data derived from these reports to be sufficiently reliable for
our purposes.
To examine how medical facility staff determine sexual assault-related
risks veterans may pose, we reviewed: (1) relevant VA and VHA policies
and procedures and (2) risk assessment policies and procedures from our
judgmentally selected sample of VISNs and VA medical facilities’
residential and inpatient mental health units. We also interviewed VA,
VHA, VISN, and VA medical facility leadership officials and residential and
inpatient mental health unit managers and staff regarding the assessment
of risks. Finally, to inform our understanding of information collected
during this process, we reviewed selected portions of medical records for
all veterans at our selected medical facilities who were registered in the
state’s publicly available sex offender registry and had addresses matching
the selected medical facilities’ residential or inpatient mental health units.
Our review of these records was limited to only those veterans meeting
these criteria and should not be generalized to broader VA patient
populations.
Finally, to examine the precautions in place to prevent sexual assaults and
other safety incidents, we reviewed relevant VA, VHA, VISN, and selected
medical facility policies related to the security of residential and inpatient
mental health programs. We also interviewed VA, VHA, VISN, and selected
medical facility officials about the precautions in place to prevent sexual
assault incidents and other violent activities in the residential and
9
For the purposes of this report, we define sexual assault as any type of sexual contact or
attempted sexual contact that occurs without the explicit consent of the recipient of the
unwanted sexual activity. Assaults may involve psychological coercion, physical force, or
victims who cannot consent due to mental illness or other factors. Falling under this
definition of sexual assault are sexual activities such as forced sexual intercourse, sodomy,
oral penetration or penetration using an object, molestation, fondling, and attempted rape
or sexual assault. Victims of sexual assault can be male or female. This does not include
cases involving only indecent exposure, exhibitionism, or sexual harassment.
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GAO-11-530 Safety in VA Medical Facilities
inpatient mental health units. Finally, to assess any weaknesses in physical
security precautions at the VA medical facilities selected for this review,
we conducted an independent assessment of the precautions in place at
each of our selected medical facilities—including the testing of alarm
systems. These assessments were conducted by physical security experts
within our Forensic Audits and Investigative Services team using criteria
based on generally recognized security standards and selected VA security
requirements. Our review of physical security precautions was limited to
only those medical facilities we reviewed and does not represent results
from all VA medical facilities. For additional details about the scope and
methodology used in this report, see appendix I.
We conducted our performance audit from May 2010 through June 2011 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives. We conducted our related investigative
work in accordance with standards prescribed by the Council of the
Inspectors General on Integrity and Efficiency.
Background
VHA oversees VA’s health care system, which includes 153 medical
facilities organized into 21 VISNs. VISNs are charged with the day-to-day
management of the medical facilities within their network; however, VHA
Central Office maintains responsibility for monitoring and overseeing both
VISN and medical facility operations. These oversight functions are
housed within several offices within VHA, including the Office of the
Deputy Under Secretary for Health for Operations and Management and
the Office of the Principal Deputy Under Secretary for Health.
Residential Programs
The 237 residential programs in place in 104 VA medical facilities provide
residential rehabilitative and clinical care to veterans with a range of
mental health conditions. VA operates three types of residential programs
in selected medical facilities throughout its health care system:
•
Residential rehabilitation treatment programs (RRTP). These programs
provide intensive rehabilitation and treatment services for a range of
mental health conditions in a 24 hours per day, 7 days a week structured
residential environment at a VA medical facility. There are several types of
RRTPs throughout VA’s health care system that specialize in offering
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GAO-11-530 Safety in VA Medical Facilities
programs for the treatment and management of certain mental health
conditions—such as post-traumatic stress disorder (PTSD) and substance
abuse.
•
Domiciliary programs. In its domiciliaries, VA provides 24 hours per day,
7 days a week structured and supportive residential environments,
housing, and clinical treatment to veterans. Domiciliary programs may
also contain specialized treatment programs for certain mental health
conditions.
•
Compensated work therapy/transitional residence (CWT/TR) programs.
These programs are the least intensive residential programs and provide
veterans with community based housing and therapeutic work-based
rehabilitation services designed to facilitate successful community
reintegration. 10
Security measures that must be in place at all three types of residential
programs are governed by VHA’s Mental Health RRTP Handbook. 11 Among
the security precautions that must be in place for residential programs are
secure accommodations for women veterans and periodic assessments of
facility safety and security features. 12
Inpatient Mental Health
Units
Most (111) of VA’s 153 medical facilities have at least one inpatient mental
health unit that provides intensive treatment for patients with acute
mental health needs. These units are generally a locked unit or floor within
each medical facility, though the size of these units varies throughout VA.
Care on these units is provided 24 hours per day, 7 days a week, and is
intensive psychiatric treatment designed to stabilize veterans and
transition them to less intensive levels of care, such as RRTPs and
domiciliary programs. Inpatient mental health units are required to comply
with VHA’s Mental Health Environment of Care Checklist that specifies
several safety requirements for these units, including several security
precautions, such as the use of panic alarm systems and the security of
nursing stations within these units.
10
Compensated work therapy is a VA vocational rehabilitation program that matches workready veterans with competitive jobs, provides support to veterans in these positions, and
consults with business and industry on their specific employment needs.
11
Veterans Health Administration Handbook 1162.02, Mental Health Residential
Rehabilitation Treatment Program (Dec. 22, 2010).
12
CWT/TR programs are exempt from some of these requirements.
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GAO-11-530 Safety in VA Medical Facilities
Mental Health Admission
Screening and Assessment
The admissions processes for both VA residential programs and inpatient
mental health units require several assessments that are conducted by an
interdisciplinary team—including nursing staff, social workers, and
psychologists. One of the commonly used assessments is a comprehensive
biopsychosocial assessment. In residential programs, these assessments
are required to be completed within 5 days of admission and include the
collection of veterans’ medical, psychiatric, social, developmental, legal,
and abuse histories along with other key information. 13 These
biopsychosocial assessments aid in the development of individualized
treatment plans based on each veteran’s individual needs. For inpatient
mental health units, initial screening of veterans, including the initial
biopsychosocial assessment, often takes place outside the unit in another
area of the medical facility where the veteran first presents for treatment,
such as the emergency room or a mental health outpatient clinic. Veterans
admitted to inpatient mental health units are typically reassessed more
frequently than veterans admitted to residential programs due to their
instability at the time of admission.
VA Law Enforcement
Resources
VA’s OSLE is the department-level office within VA Central Office
responsible for developing policies and procedures for VA’s law
enforcement programs at local VA medical facilities. Most VA medical
facilities have a cadre of VA police officers who are federal law
enforcement officers who report to the medical facility’s director. These
officers are charged with protecting the medical facility by responding to
and investigating potentially criminal activities reported by staff, patients,
and others within the medical facility and completing police reports about
these investigations. VA medical facility police often notify and coordinate
with other law enforcement entities, including local area police
departments and the VA OIG, when criminal activities or potential security
threats occur.
The VA OIG has investigators throughout the nation who also conduct
investigations of criminal activities affecting VA operations, including
reported cases of sexual assault. By regulation, all potential felonies,
13
Information about veterans’ living situations, emotional and behavioral functioning,
histories of substance use, family psychiatric histories, experiences with military history
and trauma, current social support and stressors, and current financial status may also be
included in these assessments.
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GAO-11-530 Safety in VA Medical Facilities
including rape allegations, must be reported to VA OIG investigators. 14
Once a case is reported, VA OIG investigators can either serve as the lead
agency on the case or offer to serve as advisors to local VA police or other
law enforcement agencies conducting an investigation of the issue.
In April 2010, VA established an Integrated Operations Center (IOC) that
serves as the department’s centralized location for integrated planning and
data analysis on serious incidents. 15 The VA IOC requires incidents—
including sexual assaults—that are likely to result in media or
congressional attention be reported to the IOC within 2 hours of the
incident. The IOC then presents information on serious incidents to VA
senior leadership officials, including the Secretary in some cases.
14
38 C.F.R. § 1.204 (2010). Criminal matters involving felonies must be immediately referred
to the OIG, Office of Investigations. VA management officials with information about
possible criminal matters involving felonies are responsible for prompt referrals to the OIG.
Examples of felonies include but are not limited to, theft of government property over
$1,000, false claims, false statements, drug offenses, crimes involving information
technology systems, and serious crimes against the person,
i.e., homicides, armed robbery, rape, aggravated assault, and serious physical abuse of a
VA patient. Additionally, another VA regulation requires that all VA employees with
knowledge or information about actual or possible violations of criminal law related to
VA programs, operations, facilities, contracts, or information technology systems
immediately report such knowledge or information to their supervisor, any management
official, or directly to the VA OIG. 38 C.F.R. § 1.201 (2010).
15
VA defines serious incidents as those that involve: (1) public information regarding the
arrest of a VA employee; (2) major disruption to the normal operations of a VA facility;
(3) deaths on VA property due to suspected homicide, suicides, accidents, and/or
suspicious deaths; (4) VA police-involved shootings; (5) the activation of occupant
emergency plans, facility disaster plans, and/or continuity of operations plans; (6) loss or
compromise of VA sensitive data, including classified information; (7) theft or loss of VAcontrolled firearms or hazardous material, or other major theft or loss; (8) terrorist event
or credible threat that impacts VA facilities or operations; and (9) incidents on VA property
that result in serious illness or bodily injury, including sexual assault, aggravated assault,
and child abuse. See VA Directive 0321, Serious Incident Reports (Jan. 21, 2010).
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GAO-11-530 Safety in VA Medical Facilities
Nearly 300 Sexual
Assault Incidents
Were Reported Since
2007 through One of
Two VA Reporting
Streams
VA has two concurrent reporting streams—a management stream and a
law enforcement stream—for communicating sexual assaults and other
safety incidents to senior leadership officials. The management stream
identifies and documents incidents for leadership’s attention. The law
enforcement stream documents incidents that may involve criminal acts
for investigation and prosecution, when appropriate. We found that there
were nearly 300 sexual assault incidents reported through the law
enforcement stream to the VA police from January 2007 through July
2010—including alleged incidents that involved rape, inappropriate
touching, forceful medical examinations, forced or inappropriate oral sex,
and other types of sexual assault incidents. Finally, we could not
systematically analyze sexual assault incident reports received through
VA’s management stream due to the lack of a centralized VA management
reporting system.
VA Uses Two Reporting
Streams for
Communicating Incidents
to Management and Law
Enforcement
Policies and processes are in place for documenting and communicating
sexual assaults and other safety incidents to VHA management and VA law
enforcement officials. VHA policies outline what information staff must
report and define some mechanisms for this reporting, but medical
facilities have the flexibility to customize and design their own sitespecific reporting systems and policies that fit within the broad context of
these requirements.
VA’s structure for reporting sexual assaults and other safety incidents
involves two concurrent reporting streams—the management stream and
the law enforcement stream. This dual reporting process is intended to
ensure that both relevant medical facility leadership and law enforcement
officials are informed of incidents and can perform their own separate
investigations. (See fig. 1 for an illustration of the reporting structure for
sexual assaults and other safety incidents.) The reporting processes
described below may vary slightly throughout VA medical facilities due to
local medical facility policies and procedures.
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GAO-11-530 Safety in VA Medical Facilities
Figure 1: VA Reporting Process for Sexual Assaults and Other Safety Incidents
At the
facility level:a
At the
VISN level:
Quality/unit
management
review
Management
stream of
reporting:
Facility
leadership
review and
determine
next reporting
steps
VISN
management
review and
determine
next reporting
steps
At the
VHA level:
At the
VA department level:
VHA
management
and program
offices
determine
next reporting
steps
Office of the
Secretary
reviews
reports
Staff
report
incident
Law
enforcement
stream of
reporting:
Facility police
generate
report and
conduct
investigation
VA IOC
receives
reports of
serious
incidents
VA OIG
receives
reports of and
investigates
potential
feloniesb
VA OSLE
receives
electronic
reports of
all incidents
Source: GAO.
a
Facility reporting processes described in this graphic are based on our review of five selected VA
medical facilities.
b
VA OIG receives reports of potential felonies through additional reporting streams, including the VA
OIG hotline and congressional contacts.
Management reporting stream. This stream—which includes reporting
responsibilities at the local medical facility, VISN, and VHA Central Office
levels—is intended to help ensure that incidents are identified and
documented for leadership’s attention.
•
Local VA medical facilities. Local incident reporting is the first step in
communicating safety issues, including sexual assault incidents, to VISN
and VHA Central Office officials and was handled through a variety of
electronic facility based systems at the medical facilities we visited. The
processes were similar in all five medical facilities we visited and were
initiated by the first staff member who observed or was notified of an
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GAO-11-530 Safety in VA Medical Facilities
incident completing an incident report in the medical facility’s electronic
reporting system. The medical facility’s quality manager then reviewed the
electronic report, while the staff member was responsible for
communicating the incident through his or her immediate supervisor or
unit manager. VA medical facility leadership at the locations we visited
reported that they are informed of incidents at morning meetings or
through immediate communications, depending on the severity of the
incident. Medical facility leadership officials are responsible for reporting
serious incidents to the VISN.
•
VISNs. Officials in network offices we reviewed told us that their medical
facilities primarily report serious incidents to their offices through two
mechanisms—issue briefs and “heads up” messages. 16 Issue briefs
document specific factual information and are forwarded from the medical
facility to the VISN. Heads up messages are early notifications designed to
allow medical facility and VISN leadership to provide a brief synopsis of
the issue while facts are being gathered for documentation in an issue
brief. VISN offices are typically responsible for direct reporting to the VHA
Central Office.
•
VHA Central Office. An official in the VHA Office of the Deputy Under
Secretary for Health for Operations and Management said that VISNs
typically report all serious incidents to this office. This office then
communicates relevant incidents to other VHA offices, including the Office
of the Principal Deputy Under Secretary for Health, through an e-mail
distribution list.
Law enforcement reporting stream. The purpose of this stream is to
document incidents that may involve criminal acts so they can be
investigated and prosecuted, if appropriate. The law enforcement
reporting stream involves local VA police, VA’s OSLE, VA’s IOC, and the
VA OIG.
•
Local VA police. At the medical facilities we visited, local policies require
medical facility staff to notify the medical facility’s VA police of incidents
that may involve criminal acts, such as sexual assaults. According to VA
officials, when VA police officers observe or are notified of an incident
they are required to document the allegation in VA’s centralized police
reporting system.
16
Several VISN officials in network offices we reviewed also noted that they can sometimes
learn of incidents through other mechanisms, such as press reports and veterans’ families.
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GAO-11-530 Safety in VA Medical Facilities
•
VA’s OSLE. This office receives reports of incidents at VA medical
facilities through its centralized police reporting system. Additionally,
local VA police are required to immediately notify VA OSLE of serious
incidents, including reports of rape and aggravated assaults.
•
VA’s IOC. Serious incidents on VA property—those that result in serious
bodily injury, including sexual assaults—are reported to the IOC either by
local VA police or the VHA Office of the Deputy Under Secretary for
Health for Operations and Management. Incidents reported to the IOC are
communicated to the Secretary of VA through serious incident reports and
to other senior staff through daily reports.
•
VA OIG. Federal regulation requires that all potential felonies, including
rape allegations, be reported to VA OIG investigators. 17 In addition, VHA
policy reiterates this requirement by specifying that the OIG must be
notified of sexual assault incidents when the crime occurs on VA premises
or is committed by VA employees. 18 At the VA medical facilities we visited,
officials told us that either the medical facility’s leadership team or VA
police are responsible for reporting all incidents that are potential felonies
to the VA OIG. The VA OIG may also learn of incidents from staff, patients,
congressional communications, or the VA OIG hotline for reporting fraud,
waste, and abuse. When the VA OIG is notified of a potential felony, their
investigators document both their contact with medical facility officials or
other sources and the initial case information they receive.
Nearly 300 Sexual Assault
Incidents Reported to VA
Police through the Law
Enforcement Stream Since
2007
We analyzed VA’s national police files from January 2007 through July
2010 and identified 284 sexual assault incidents reported to VA police
during that period. 19 These cases included incidents alleging rape,
inappropriate touching, forceful medical examinations, oral sex, and other
types of sexual assaults (see table 1). 20 However, it is important to note
that not all sexual assault incidents reported to VA police are
17
See 38 C.F.R. § 1.204 (2010).
18
VHA Directive 2010-014, Assessment and Management of Veterans Who Have Been
Victims of Alleged Acute Sexual Assault (May 25, 2010).
19
Our analysis was limited to only those reports that were provided by the VA OSLE and
does not include reports that may never have been created or were lost by local VA police
or VA OSLE.
20
To conduct this analysis, we placed VA police case files into these categories to describe
the allegations contained within them.
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GAO-11-530 Safety in VA Medical Facilities
substantiated. A case may remain unsubstantiated because an assault did
not actually take place, the victim chose not to pursue the case, or there
was insufficient evidence to substantiate the case. Due to our review of
both open and closed VA police sexual assault incident investigations, we
could not determine the final disposition of these incidents. 21
Table 1: Number of Sexual Assault Incidents by Category Reported to VA Police by
Year, January 2007 through July 2010
Rapea
Inappropriate
b
touch
Forceful
medical
examination
Forced or
inappropriate
oral sex
Other
c
Total
2010
14
44
3
5
0
66
2009
23
66
3
3
9
104
Year
d
e
2008
13
42
1
3
1
60
2007e,f
17
33
1
2
1
54
g
67
185
8
13
11
284
Total
Source: GAO (analysis); VA (data).
Note: In this report, we use the term sexual assault incident to refer to suspected, alleged, attempted,
or confirmed cases of sexual assault. All reports of sexual assault incidents do not necessarily lead to
prosecution and conviction. This may be, for example, because an assault did not actually take place
or there was insufficient evidence to determine whether an assault occurred.
a
The rape category includes any case involving allegations of rape, defined as vaginal or anal
penetration through force, threat, or inability to consent. For cases that included allegations of
multiple categories including rape (i.e., inappropriate touch, forced oral sex, and rape) the category of
rape was applied. Cases where staff deemed that one or more of the veterans involved were mentally
incapable of consenting to sexual activities described in the case were considered rape.
b
The inappropriate touch category includes any case involving only allegations of touching, fondling,
grabbing, brushing, kissing, rubbing, or other like-terms.
c
The other category included any allegations that did not fit into the other categories or if the incident
described in the case file did not contain sufficient information to place the case in one of the other
designated categories.
d
Analysis of 2010 records was limited to only those received by VA police through July 2010.
e
Due to the lack of a centralized VA police reporting system prior to January 2009, VA medical facility
police sent reports to VA’s OSLE for the purpose of this data request, which may have resulted in not
all reports being included in this analysis.
f
Our ability to review files for the entire year was limited because VA police are required to destroy
files after 3 years under a records schedule approved by the National Archives and Records
Administration (NARA).
g
Cases not reported to VA police were not included in our analysis of sexual assault incidents.
21
We could not consistently determine whether or not these sexual assault incidents were
substantiated due to limitations in the information VA provided, including inconsistent
documentation of the disposition of some incidents in the police files.
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GAO-11-530 Safety in VA Medical Facilities
In analyzing these 284 cases, we observed the following (see app. II for
additional analysis of VA police reports):
•
Overall, the sexual assault incidents described above included several
types of alleged perpetrators, including employees, patients, visitors,
outsiders not affiliated with VA, and persons of unknown affiliation. In the
reports we analyzed, there were allegations of 89 patient-on-patient sexual
assaults, 85 patient-on-employee sexual assaults, 46 employee-on-patient
sexual assaults, 28 unknown affiliation-on-patient sexual assaults, and
15 employee-on-employee sexual assaults. 22
•
Regarding gender of alleged perpetrators, we also observed that of the
89 patient-on-patient sexual assault incidents, 46 involved allegations of
male perpetrators assaulting female patients, 42 involved allegations of
male perpetrators assaulting male patients, and 1 involved an allegation of
a female perpetrator assaulting a male patient. Of the 85 patient-onemployee sexual assault incidents, 83 involved allegations of male
perpetrators assaulting female employees and 2 involved allegations of
male perpetrators assaulting male employees.
We could not systematically analyze sexual assault incidents reported
through VA’s management stream due to the lack of a centralized VA
management reporting system for tracking sexual assaults and other
safety incidents.
Not All Sexual Assault
Incidents Are
Reported Due to
Unclear Guidance and
Insufficient Oversight
Despite the VA police receiving reports of nearly 300 sexual assault
incidents since 2007, sexual assault incidents are underreported to
officials within the management reporting stream and the VA OIG. Factors
that may contribute to the underreporting of sexual assault incidents
include the lack of both a clear definition of sexual assault and
expectations on what incidents should be reported, as well as deficient
VHA Central Office oversight of sexual assault incidents.
22
Other allegations by relationship included: 1 employee-on-outsider assault, 2 employeeon-visitor assaults, 2 outsider-on-employee assaults, 2 outsider-on-outsider assaults,
1 outsider-on-patient assault, 1 outsider-on-visitor assault, 3 patient-on-visitor assaults,
3 unknown-on-employee assaults, 3 unknown-on-visitor assaults, 1 visitor-on-employee
assault, and 2 visitor-on-patient assaults.
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GAO-11-530 Safety in VA Medical Facilities
Sexual Assault Incidents
Are Underreported to
VISNs, VHA Central Office,
and the VA OIG
Sexual assault incidents are underreported to both VHA officials at the
VISN and VHA Central Office levels and the VA OIG. Specifically, VISN and
VHA Central Office officials did not receive reports of all sexual assault
incidents reported to VA police in VA medical facilities within the four
VISNs we reviewed. In addition, the VA OIG did not receive reports of all
sexual assault incidents that were potential felonies as required by VA
regulation, specifically those involving rape allegations.
VISNs and VHA Central Office
Receive Limited Information on
Sexual Assault Incidents
VISNs and VHA Central Office leadership officials are not fully aware of
many sexual assaults reported at VA medical facilities. For the four VISNs
we spoke with, we reviewed all documented incidents reported to VA
police from medical facilities within each network and compared these
reports with the issue briefs received through the management reporting
stream by VISN officials. Based on this analysis, we determined that VISN
officials in these four networks were not informed of most sexual assault
incidents that occurred within their network medical facilities. 23 Moreover,
we also found that one VISN did not report all of the cases they received to
VHA Central Office (see table 2).
23
Our review of the reports received by both VISN and VA Central Office officials was
limited to only those documented in issue briefs and did not include the less formal headsup messages. This is because heads-up messages are not formally documented and often
are a preliminary step to a more formal issue brief.
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GAO-11-530 Safety in VA Medical Facilities
Table 2: Sexual Assault Incidents Reported to Four Selected VISNs and VHA
Central Office Leadership, January 2007 through July 2010
VISN
Total number of sexual Total number of sexual Total number of sexual
assault incidents
assault incidents
assault incidents
reported to VA police
reported to VISN
reported by VISNs to
from VISN medical
leadership by VISN
VHA Central Office
facilitiesa,b
medical facilities
leadership
VISN A
13
0
0
VISN B
21
10
5
VISN C
34
4
4
VISN D
34
2
2
Source: GAO (data and analysis); VA (data).
Note: In this report, we use the term sexual assault incident to refer to suspected, alleged, attempted,
or confirmed cases of sexual assault. All reports of sexual assault incidents do not necessarily lead to
prosecution and conviction. This may be, for example, because an assault did not actually take place
or there was insufficient evidence to determine whether an assault occurred.
a
Cases not reported to VA police were not included in our count of sexual assault incidents.
b
Due to the absence of system wide requirements on what medical facilities must report to these
VISNs, we could not determine the accuracy of VISN reporting.
The VA OIG Did Not Receive
Reports of about Two-Thirds of
Sexual Assault Incidents
Involving Rape Allegations
To examine whether VA medical facilities were accurately reporting
sexual assault incidents involving rape allegations to the VA OIG, we
reviewed both the 67 rape allegations reported to the VA police from
January 2007 through July 2010 and all investigation documentation
provided by the VA OIG for the same period. We found no evidence that
about two-thirds (42) of these rape allegations had been reported to the
VA OIG. 24 The remaining 25 had matching VA OIG investigation
documentation, indicating that they were correctly reported to both the
VA police and the VA OIG.
By regulation, VA requires that: (1) all criminal matters involving felonies
that occur in VA medical facilities be immediately referred to the VA OIG
and (2) responsibility for the prompt referral of any possible criminal
matters involving felonies lies with VA management officials when they
24
We did not require VA OIG to provide documentation for 9 incidents currently under
investigation due to the sensitive nature of these ongoing investigations. Since we did not
require this documentation, it is possible that some of these 9 ongoing investigations were
included in the 42 rape allegations we could not confirm were reported to the VA OIG.
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GAO-11-530 Safety in VA Medical Facilities
are informed of such matters. 25 This regulation includes rape in the list of
felonies provided as examples and also requires VA medical facilities to
report other sexual assault incidents that meet the criteria for felonies to
,
the VA OIG. 26 27 However, the regulation does not include criteria for how
VA medical facilities and management officials should determine whether
or not a criminal matter meets the felony reporting threshold. We found
that all 67 of these rape allegations were potential felonies because if
substantiated, sexual assault incidents involving rape fall within federal
sexual offenses that are punishable by imprisonment of more than 1 year.
In addition, we provided the VA OIG the opportunity to review summaries
of the 42 rape allegations we could not confirm were reported to them by
the VA police. To conduct this review, several VA OIG senior-level
investigators determined whether or not each of these rape allegations
should have been reported to them based on what a reasonable law
enforcement officer would consider a felony. According to these
investigators, a reasonable law enforcement officer would look for several
elements to make this determination, including (1) an identifiable and
reasonable suspect, (2) observations by a witness, (3) physical evidence,
or (4) an allegation that appeared credible. These investigators based their
determinations on their experience as federal law enforcement agents.
Following their review, these investigators also found that several of these
rape allegations were not appropriately reported to the VA OIG as required
by federal regulation. Specifically, the VA OIG investigators reported that
they would have expected approximately 33 percent of the 42 rape
25
See 38 C.F.R. § 1.204 (2010). Examples of felonies listed in this regulation include theft of
government property over $1,000, false claims, false statements, drug offenses, crimes
involving information technology systems, and serious crimes against the person,
i.e., homicides, armed robbery, rape, aggravated assault, and serious physical abuse of a
VA patient.
26
The VA Security and Law Enforcement Handbook defines a felony as any offense
punishable by either imprisonment of more than 1 year or death as classified under
18 U.S.C. § 3559. See VA Handbook 0730, Security and Law Enforcement (Aug. 11, 2000).
Federal statutes define certain sexual acts and contacts as federal crimes. See 18 U.S.C.
§§ 2241-2248. All federal sexual offenses are punishable by imprisonment of more than
1 year; therefore all federal sexual offenses are felonies and must be immediately referred
to the VA OIG for investigation in accordance with VA regulation.
27
For the purposes of our analysis, we focused only on sexual assault incidents involving
rape allegations. Neither federal statutes nor VA regulations define rape; however, the
definition of rape we developed for our analysis falls within the federal sexual offenses of
either aggravated sexual abuse or sexual abuse. See 18 U.S.C. §§ 2241 and 2242. These two
offenses are felonies under federal statute; therefore, all rapes that meet our definition are
felonies.
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GAO-11-530 Safety in VA Medical Facilities
allegations to have been reported to them based on the incident summary
containing information on these four elements. The investigators noted
that they would not have expected approximately 55 percent of the
42 rape allegations to have been reported to them due to either the
incident summary failing to contain these same four elements or the
presence of inconsistent statements made by the alleged victims. 28 For the
approximately 12 percent remaining, the investigators noted that the need
for notification was unclear because there was not enough information in
the incident summary to make a determination about whether or not the
rape allegation should have been reported to the VA OIG.
Several Factors May
Contribute to the
Underreporting of Sexual
Assault Incidents
There are several factors that may contribute to the underreporting of
sexual assault incidents to VISNs, VHA Central Office, and the VA OIG—
including VHA’s lack of a consistent sexual assault definition for reporting
purposes; limited and unclear expectations for sexual assault incident
reporting at the VHA Central Office, VISN, and VA medical facility levels;
and deficiencies in VHA Central Office oversight of sexual assault
incidents.
VHA Does Not Have a
Consistent Sexual Assault
Definition for Reporting
Purposes
VHA leadership officials may not receive reports of all sexual assault
incidents that occur at VA medical facilities because VHA does not have a
VHA-wide definition of sexual assault used for incident reporting. We
found that VHA lacks a consistent definition for the reporting of sexual
assaults through the management reporting stream at the medical facility,
VISN, and VHA Central Office levels. At the medical facility level, we found
that the medical facilities we visited had a variety of definitions of sexual
assault targeted primarily to the assessment and management of victims of
recent sexual assaults. Specifically, facilities varied in the level of detail
provided by their policies, ranging from one facility that did not include a
definition of sexual assault in its policy at all to another facility with a
policy that included a detailed definition. (See table 3.)
28
The VA OIG senior-level investigators who conducted this review noted that they
identified at least one incident summary that was readily identifiable as a case currently
under investigation by the VA OIG. Due to the general nature of the incident summaries we
provided for their review and the sensitive nature of specific details of ongoing
investigations, we did not require the VA OIG to provide specific details on exactly how
many of the 42 rape allegations we asked them to review were currently under
investigation by their office; however, the total number of ongoing sexual assault incident
investigations for the time period of our analysis was only nine.
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GAO-11-530 Safety in VA Medical Facilities
Table 3: Selected VA Medical Facility Definitions of Sexual Assault for the Assessment and Management of Victims of Recent
Sexual Assault
Selected VA medical facility
Definitions of sexual assault
Facility A
Sexual violation of a person (male or female) by the use of force, threat, or intimidation [that] is
committed without the consent of the person assaulted. The violent act may or may not include
penetration and may be [an] oral, anal, or vaginal violation.
Facility B
No definition
Facility C
Conduct of a sexual or indecent nature toward another person that is accompanied by actual or
threatened physical force or that induces fear, shame, or mental suffering. Sexual assault may be
penetrating (i.e., rape) to include vaginal, anal, and oral penetration, or nonpenetrat[ing] and
includes both males and females as victims of this crime.
Facility D
Includes incest, oral copulation, penetration, rape, sexual assault, sexual battery, and sodomy
which occurs without the consent of a person, or when a person is not capable of giving consent.
Sexual abuse also means acts of a sexual nature committed in the presence of a vulnerable adult
without that person’s informed consent. It includes, but is not limited to, the acts defined in a state
statute, fondling, exposure of a vulnerable adult’s sexual organs, or the use of a vulnerable adult
to solicit for or engage in prostitution or sexual performance.
Facility E
Sexual assault is sexual contact of ANY kind against a person’s will, brought about by force,
threats, or coercion.
Source: Selected VA medical facilities.
At the VISN level, VISN officials within the four networks we spoke with
reported that they did not have definitions of sexual assault in VISN
policies. However, some VISN officials stated they used other common
definitions, including those from the National Center for Victims of Crime
,
and The Joint Commission. 29 30 Finally, while the VHA Central Office does
have a policy for the clinical management of sexual assaults, this policy is
targeted to the treatment of victims assaulted within 72 hours and does not
include sexual assault incidents that occur outside of this time frame. In
29
The National Center for Victims of Crime’s definition of sexual assault states that: “Sexual
assault takes many forms including attacks such as rape or attempted rape, as well as any
unwanted sexual contact or threats. Usually a sexual assault occurs when someone
touches any part of another person’s body in a sexual way, even through clothes, without
that person’s consent. Some types of sexual acts which fall under the category of sexual
assault include forced sexual intercourse (rape), sodomy (oral or anal sexual acts), child
molestation, incest, fondling and attempted rape.”
30
The Joint Commission is an independent organization that accredits and certifies health
care organizations and programs in the United States. Rape is included among The Joint
Commission’s list of reportable sentinel events and defines rape as: “unconsented sexual
contact involving a patient and another patient, staff member, or other perpetrator while
being cared for, treated, or provided services, or on the premises of the behavioral health
care organization, including oral, vaginal, or anal penetration or fondling of the patient’s
sex organ(s) by another individual’s hand, sex organ, or object.”
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GAO-11-530 Safety in VA Medical Facilities
addition, neither this definition of sexual assault nor any other is included
in VHA Central Office reporting guidance, which specifies the types of
incidents that should be reported to VHA management officials.
VHA Central Office, VISNs, and
VA Medical Facilities’
Expectations for Reporting Are
Limited and Unclear
In addition to failing to provide a consistent definition of sexual assault for
incident reporting, VHA also does not have clearly documented
expectations about the types of sexual assault incidents that should be
reported to officials at each level of the organization, which may also
contribute to the underreporting of sexual assault incidents. Without clear
expectations for incident reporting there is no assurance that all sexual
assault incidents are appropriately reported to officials at the VHA Central
Office, VISN, and local medical facility levels. We found that expectations
were not always clearly documented, resulting in either the
underreporting of some sexual assault incidents or communication
breakdowns at all levels.
•
VHA Central Office. An official from VHA’s Office of the Deputy Under
Secretary for Health for Operations and Management told us that this
office’s expectations for reporting sexual assault incidents were
documented in its guidance for the submission of issue briefs. However,
we found that this guidance does not specifically reference reporting
requirements for any type of sexual assault incidents. As a result, VISNs
we reviewed did not consistently report sexual assault incidents to VHA
Central Office. For example, officials from one VISN reported sending
VHA Central Office only 5 of the 10 issue briefs they received from medical
facilities in their network, while officials from two other VISNs reported
forwarding all issue briefs on sexual assault incidents they received. 31
•
VISNs. The four VISNs we spoke with did not include detailed
expectations regarding whether or not sexual assault incidents should be
reported to them in their reporting guidance, potentially resulting in
medical facilities failing to report some incidents. 32 For example, officials
from one VISN told us they expect to be informed of all sexual assault
incidents occurring in medical facilities within their network, but this
expectation was not explicitly documented in their policy. We found
several reported allegations of sexual assault incidents in medical facilities
in this VISN—including three allegations of rape and one allegation of
31
The remaining VISN did not report receiving any issue briefs on sexual assault incidents.
32
While two of the four VISN policies reference The Joint Commission’s definition of
sentinel events, which includes rape, this definition does not include the broader category
of sexual assault incidents as defined in this report.
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GAO-11-530 Safety in VA Medical Facilities
inappropriate oral sex—that were not forwarded to VISN officials. When
asked about these four allegations, VISN officials told us that they would
only have expected to be notified of two of them—one allegation of rape
and one allegation of inappropriate oral sex—because the medical
facilities where they occurred contacted outside entities, including the VA
OIG. VISN officials explained that the remaining two rape allegations were
unsubstantiated and were not reported to their office; the VISN also noted
that unsubstantiated incidents are not often reported to them.
•
Deficiencies Exist in VHA
Central Office Oversight of
Sexual Assault Incidents
VA medical facilities. At the medical facility level, we also found that
reporting expectations may be unclear. In particular, we identified cases in
which the VA police had not been informed of incidents that were
reported to medical facility staff. For example, we identified VA police
files from one facility we visited where officers noted that the alleged
perpetrator had been previously involved in other sexual assault incidents
that were not reported to the VA police by medical facility staff. In these
police files, officers noted that staff working in the alleged perpetrators’
units had not reported the previous incidents because they believed these
behaviors were a manifestation of the veterans’ clinical conditions. We
also observed cases of communication breakdowns during our discussions
with medical facility officials and clinicians. For example, at one medical
facility VA police reported that prior to our arrival they were not
immediately informed of an alleged sexual assault incident involving two
male patients in the dementia ward that occurred the previous evening. As
a result, VA police were unable to immediately begin their investigation
because staff from the unit had completed their shifts and left the ward. At
another medical facility we visited, quality management staff identified
five sexual assault incidents that had not been reported to VA police at the
medical facility, despite these incidents being reported to their office.
The VHA Central Office also had deficiencies in several necessary
oversight elements that could contribute to the underreporting of sexual
assault incidents to VHA management—including information-sharing
practices and systems to monitor sexual assault incidents reported
through the management reporting stream. Specifically, the VHA Central
Office has limited information-sharing practices for distributing
information about reported sexual assault incidents among VHA Central
Office officials and has not instituted a centralized tracking mechanism for
these incidents.
Currently, the VHA Central Office relies primarily on e-mail messages to
transfer information about sexual assault incidents among its offices and
staff (see fig. 2). Under this system, the VHA Central Office is notified of
sexual assault incidents through issue briefs submitted by VISNs via e-mail
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GAO-11-530 Safety in VA Medical Facilities
to one of three VISN support teams within the VHA Office of the Deputy
Under Secretary for Health for Operations and Management. 33 These issue
briefs are then forwarded to the Director for Network Support within this
office for review and follow-up with VA medical facilities if needed. 34
Following review, the Director for Network Support forwards issue briefs
to the Office of the Principal Deputy Under Secretary for Health for
distribution to other VHA offices on a case-by-case basis, including the
program offices responsible for residential programs and inpatient mental
health units. Program offices are sometimes asked to follow up on
incidents in their area of responsibility.
Figure 2: VHA Central Office Reporting Process for Sexual Assaults and Other Safety Incidents
At the
facility level
At the
VISN level
At the
VHA level:
At the
VA department level
VHA Office of the Deputy Under Secretary for
Health for Operations and Management:
VHA Office of the Principal Deputy
Under Secretary for Health:
VISN support
staff receive
issue briefs
from VISNs
via e-mail
Receives and
distributes
issue briefs
to other VHA
offices via
e-mail
Director of
Network
Support
reviews and
forwards
issue briefsb
VHA Program Offices:a
Program
officials
receive issue
briefs and
follow-up with
facilities as
necessary
Source: GAO.
a
Program offices include those responsible for residential programs and inpatient mental health units.
b
Office of the Deputy Under Secretary for Health for Operations and Management officials reported
that they may distribute issue briefs directly to program officials depending on the severity of the
incident.
33
VISNs may also send a heads-up message to this office either by e-mail or phone to inform
the Office of the Deputy Under Secretary for Health for Operations and Management of
emerging incidents. These heads-up messages are typically the precursor to issue briefs
received by the office.
34
The Director for Network Support is a senior executive who advises the Assistant Deputy
Under Secretary for Health Care Management.
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GAO-11-530 Safety in VA Medical Facilities
We found that this system did not effectively communicate information
about sexual assault incidents to the VHA Central Office officials who
have programmatic responsibility for the locations in which these
incidents occurred. For example, VHA program officials responsible for
both residential programs and inpatient mental health units reported that
they do not receive regular reports of sexual assault incidents that occur
within their programs or units at VA medical facilities and were not aware
of any incidents that had occurred in these programs or units. However,
during our review of VA police files we identified at least 18 sexual assault
incidents that occurred from January 2007 through July 2010 in the
residential programs or inpatient mental health units of the five VA
medical facilities we reviewed. If the management reporting stream were
functioning properly, these program officials should have been notified of
these incidents and any others that occurred in other VA medical facilities’
residential programs and inpatient mental health units. 35 Without the
regular exchange of information on sexual assault incidents that occur
within their areas of programmatic responsibility, VHA program officials
cannot effectively address the risks of such incidents in their programs
and units and do not have the opportunity to identify ways to prevent
incidents from occurring in the future.
In early 2011, VHA leadership officials told us that initial efforts, including
sharing information about sexual assault incidents with the Women
Veterans Health Strategic Health Care Group and VHA program offices,
were under way to improve how information on sexual assault incidents is
communicated to program officials. However, these improvements have
not been formalized within VHA or published in guidance or policies and
are currently being performed on an informal ad hoc basis only, according
to VHA officials.
In addition to deficiencies in information sharing, we also identified
deficiencies in the monitoring of sexual assault incidents within the VHA
Central Office. VHA’s Office of the Deputy Under Secretary for Health for
Operations and Management, the first VHA office to receive all issue briefs
related to sexual assault incidents, does not currently have a system that
allows VHA Central Office staff to systematically review or analyze reports
35
See GAO, Internal Control: Standards for Internal Control in the Federal Government,
GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999). Standards for internal control in
the federal government state that information should be recorded and communicated to
management and others within the agency that need it in a format and time frame that
enables them to carry out their responsibilities.
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GAO-11-530 Safety in VA Medical Facilities
of sexual assault incidents received from VA medical facilities through the
management reporting stream. Specifically, we found that this office does
not have a central database to store the issue briefs that it receives and
instead relies on individual staff to save issue briefs submitted to them by
e-mail to electronic folders for each VISN. In addition, officials within this
office said they do not know the total number of issue briefs submitted for
sexual assault incidents because they do not have access to all former staff
members’ files. As a result of these issues, staff from the Office of the
Deputy Under Secretary for Health for Operations and Management could
not provide us with a complete set of issue briefs on sexual assault
incidents that occurred in all VA medical facilities without first contacting
VISN officials to resubmit these issue briefs. 36 Such a limited archive
system for reports of sexual assault incidents received through the
management reporting stream results in VHA’s inability to track and trend
sexual assault incidents over time. While VHA has, through its National
Center for Patient Safety (NCPS), developed systems for routinely
monitoring and tracking patient safety incidents that occur in VA medical
facilities, these systems do not monitor sexual assaults and other safety
incidents. Without a system to track and trend over time sexual assaults
and other safety incidents, the VHA Central Office cannot identify and
make changes to serious problems that jeopardize the safety of veterans in
their medical facilities.
36
See GAO/AIMD-00-21.3.1. Standards for internal control in the federal government state
that agencies should design internal controls that assure ongoing monitoring occurs in the
course of normal operations, is continually performed, and is ingrained in agency
operations.
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GAO-11-530 Safety in VA Medical Facilities
Self-Reported Legal
Histories Are
Commonly Used to
Inform Clinicians of
Sexual AssaultRelated Risks, but
Guidance on
Information
Collection Is Limited
VA does not have risk assessment tools specifically designed to examine
sexual assault-related risks that some veterans may pose while they are
being treated at VA medical facilities. 37 Instead, VA clinicians working in
the residential programs and inpatient mental health units at medical
facilities we visited said they rely mainly on information about veterans’
legal histories, including a veteran’s history of violence, which are
examined as part of a multidisciplinary admission assessment process to
assess these and other risks veterans pose to themselves and others.
Clinicians also reported that they generally rely on veterans’ self-reported
information, though this information is not always complete or accurate.
Finally, we found that VHA’s guidance on the collection of legal history
information in residential programs and inpatient mental health units does
not specify the type of legal history information that should be collected
and documented.
VHA Does Not Have
Specific Sexual Assault
Risk Assessment Tools
VHA officials and clinicians working in the residential programs and
inpatient mental health units at medical facilities we visited told us that
VHA does not have risk assessment tools specifically designed to examine
sexual assault-related risks that some veterans may pose while being
treated at VA medical facilities. However, these officials and clinicians
noted that such risks are assessed and managed by clinical staff.
VHA officials told us that since no evidence-based risk assessment tool for
sexual assault and other types of violence exists, VHA relies on the
professional judgment of clinicians to identify and manage risks through
appropriate interventions. To do this, VA clinicians generally assess the
overall risks veterans pose to themselves or others in the VA population by
reviewing veterans’ medical records and conducting various
interdisciplinary assessments. Specifically, clinicians said that they review
medical records for information about veterans’ potential for violence and
medical conditions. In addition, the interdisciplinary assessments
clinicians are required to conduct include biopsychosocial assessments,
nursing assessments, suicide risk assessments, and other program-specific
37
We did not review the sexual assault-related risks that VA staff and clinicians may pose in
VA medical facilities.
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GAO-11-530 Safety in VA Medical Facilities
assessments. 38 In residential programs and inpatient mental health units,
biopsychosocial assessments are a standard part of the admissions
process and capture several types of information clinicians can use to
assess risks veterans may pose. 39 This information includes inquiries about
veterans’ legal histories; any violence they may have experienced as either
a victim or perpetrator, including physical or sexual abuse; childhood
abuse and neglect; and military history and trauma.
Clinicians Reported Using
Veterans’ Self-Reported
Legal Histories to Assess
Sexual Assault-Related
Risks, but This
Information May Not
Always Be Complete
The examination of legal history information is an important part of
clinicians’ assessments of sexual assault risks veterans may pose.
Clinicians from all five medical facilities we visited explained that such
legal history information is primarily obtained through veterans
voluntarily self-reporting these issues during the biopsychosocial
assessment process. Clinicians also cited other sources of information that
could be used to learn about veterans’ legal issues, including family
members, the court system, probation and parole officers, VHA justice
outreach staff, and Internet searches of public registries containing
criminal justice information. However, clinicians reported limitations in
the use of several of these sources. In some cases, veterans must authorize
the disclosure of their criminal or medical information before it can be
released to a VA medical facility—although clinicians noted that veterans
who have a legal restriction on where they may reside or need to meet
probation or parole requirements while in treatment are often willing to
release information. In addition, clinicians reported challenges in
contacting veterans’ families to obtain information as many have no family
support system, particularly those who are homeless prior to entering
treatment. Further, VA’s Office of General Counsel and VHA Central Office
38
One example of a program-specific assessment used at one site we visited is the
Minnesota Multiphasic Personality Inventory (MMPI) for veterans entering the PTSD
Residential Program. Clinicians at this site said that the MMPI is the most widely used
personality inventory in the country. These clinicians explained that this instrument helps
them ensure they have essential information to make appropriate placements of veterans in
this program.
39
VHA officials told us that assessment requirements for veterans admitted to residential
programs are contained in VHA’s Mental Health RRTP Handbook and policy guidance on
assessment for inpatient mental health units is found in various documents, including the
VA/Department of Defense (DOD) PTSD Clinical Practice Guidelines (2010) and The Joint
Commission standards. See Veterans Health Administration Handbook 1162.02, Mental
Health Residential Rehabilitation Treatment Program (Dec. 22, 2010); VA/DOD Clinical
Practice Guideline for the Management of Post-Traumatic Stress (October 2010); and The
Joint Commission, 2010 Standards for Behavioral Health Care (Oakbrook Terrace, Ill.:
2010).
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GAO-11-530 Safety in VA Medical Facilities
officials told us that VHA staff cannot conduct background checks on
veterans applying for VA health care services, including Internet searches
of public sources of criminal justice information because VHA lacks legal
authority to collect or maintain this information. 40
VA clinicians from residential programs and inpatient mental health units
at the five medical facilities we visited said that although they inquire
about veterans’ past legal issues, they do not always obtain timely,
complete, or reliable information on these issues from veterans. These
clinicians noted that although many veterans are eventually forthcoming
about their legal history, some may not disclose this information during
the admission assessment or ongoing reassessment processes. For
example, clinicians told us that sometimes they learned about particular
legal issues, such as an arrest warrant or parole requirements, after
veterans have been admitted to the program or when they were being
discharged. They explained that sometimes veterans are uncomfortable
discussing legal or sexual abuse issues during their admission interviews,
but may share this information over time when they become comfortable
with their treatment team. However, these clinicians noted that sometimes
these issues do not come to light until veterans are beginning their
transitions into community housing during the discharge process.
Nevertheless, clinicians reported that they try to encourage veterans to
disclose their full legal histories because it helps them to identify and
address mental health problems that may have contributed to veterans’
encounters with the legal system and to aid the transition to independent
community living.
To determine whether legal history information in veterans’ medical
records was complete, we reviewed the biopsychosocial assessments for
seven veterans at our selected medical facilities who were registered sex
offenders and found that while nearly all of these assessments
documented that medical facility clinicians inquired about these veterans’
legal issues, these issues were not consistently included in the
assessments. 41 The extent to which information about legal history was
40
Federal agencies may only run background checks for noncriminal justice purposes if
they have specific statutory authority. See 42 U.S.C. § 14616 art. IV(b). VA police may only
conduct a background check on a veteran if the veteran is the subject of a criminal
investigation.
41
Veterans counted as registered sex offenders in our sample were those that had been
registered in the state sex offender registry for each of our selected medical facilities under
the address of either the medical facility’s residential programs or inpatient mental health
units when we checked these registries prior to our site visits.
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GAO-11-530 Safety in VA Medical Facilities
documented for these seven veterans varied—from assessments
containing detailed information about current and past criminal
convictions, including the veterans’ sex offense violations and conviction
dates, to assessments that did not contain any information about their past
or current legal history. Specifically, four of these seven assessments
contained detailed descriptions of the veterans’ legal histories including
information on sex offense violations; two of these seven assessments
contained limited descriptions of the veterans’ legal histories; and one of
these seven assessments contained no information on the veteran’s legal
history. In addition, we could not review one additional biopsychosocial
assessment for an eighth veteran who was a patient in one of our selected
medical facilities and was also listed in the publicly available state sex
offender registry for the selected medical facility because the medical
facility did not conduct a biopsychosocial assessment, as required by
policy.
Incomplete or missing information about veterans’ legal histories and
histories of violence can hinder clinicians’ abilities to effectively assess
risks, provide appropriate treatment options, and ensure the safety of all
veterans. In particular, some clinicians noted that insufficient information
about veterans’ legal backgrounds can affect their ability to make
appropriate program residency placement decisions and assist veterans in
developing appropriate housing and employment plans for their
reintegration into the community. For example, clinicians reported they
face challenges in assisting some homeless veterans in finding jobs or
housing partly because outside entities often conduct background checks
prior to accepting veterans into their programs and VA staff cannot always
effectively help veterans navigate those issues if they lack relevant or
timely information about veterans’ legal histories. Clinicians also said that
knowledge about legal issues—such as pending court appearances,
criminal charges, or sentencing requirements—is useful because such
issues can interrupt or delay rehabilitation treatment services at VA or
prevent veterans from using certain community resources when they are
discharged if not adequately addressed. Finally, clinicians said that
insufficient information about these issues affects their ability to identify
actions to manage risks and make informed resource allocation decisions,
such as increasing patient supervision, altering clinical staff assignments,
or requesting VA police assistance.
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GAO-11-530 Safety in VA Medical Facilities
VHA Does Not Have
Specific Guidance on the
Collection of Legal History
Information
VHA’s assessment of veterans in their mental health programs for sexual
assault-related risks is limited by a lack of specific guidance. 42 Although VA
clinicians are required to conduct comprehensive assessments that include
the collection of veterans’ legal histories, VHA has limited guidance on
how such information should be collected and documented in residential
programs and inpatient mental health units.
•
Residential programs. Current VHA policy for residential programs
requires that information about veterans’ legal histories and current
pending legal matters be included in biopsychosocial assessments, but
does not specify the extent to which such information should be
documented in veterans’ medical records or delineate sources that may be
used to address this requirement. 43 Specifically, this VHA policy does not
include descriptions of the type of legal history information clinicians
should document in the biopsychosocial assessment portion of veterans’
medical records. For example, there are no specific requirements for
clinicians to document past incarcerations or convictions and dates when
these events occurred. Currently, VHA delegates the responsibility for
developing specific admission policies and procedures to the VA medical
facility residential program managers, who may in turn delegate this
responsibility to appropriate staff members. We found that medical facility
level policies and procedures for the medical facilities we visited generally
mirrored VHA’s broad guidance in this area, although some medical
facilities had procedures that outlined the specific information that
clinicians should collect related to veterans’ legal backgrounds—such as
the type and date of convictions, description of pending legal charges or
warrants, and time spent in jail or prison.
•
Inpatient mental health units. VHA officials responsible for inpatient
mental health units reported that broad VHA guidance requires inpatient
mental health clinicians to conduct biopsychosocial assessments for
patients admitted to these units. However, unlike residential programs,
42
See GAO/AIMD-00-21.3.1. Standards for internal control in the federal government state
that agencies should assess risks the agency faces from both internal and external sources
and require clear, consistent agency objectives and detailed policies on the information
that medical facilities should include in risk identification. While internal control standards
allow for variation in the specific approach agencies or programs may use based on
differences in their missions or difficulty in identifying risks, having clear agency policies is
critical to the risk assessment process.
43
VHA officials reported that these requirements are based on accreditation organization
requirements, specifically The Joint Commission and the Commission on Accreditation of
Rehabilitation Facilities.
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GAO-11-530 Safety in VA Medical Facilities
there is currently no VHA policy that specifically defines how inpatient
mental health units should collect this legal history information. The broad
guidance VHA officials cited, such as the VA/DOD Clinical Practice
Guidelines for Post-Traumatic Stress and The Joint Commission
standards, requires the collection of legal history information as part of the
initial assessment, but does not fully specify the type of legal history
information that must be included in veterans’ medical records. 44 A VHA
official responsible for inpatient mental health units throughout VA
confirmed that guidance has not been issued regarding the legal history
information that may or may not be collected by clinicians in inpatient
mental health units or how information obtained from veterans should be
documented.
Without clear guidance on what legal history information should be
collected and how this information should be documented in veterans’
medical records, there is no assurance that clinicians are comprehensively
identifying and analyzing sexual assault-related risks or that legal history
information is collected and documented consistently during
biopsychosocial assessments.
VA Residential and
Inpatient Mental
Health Settings Use a
Variety of Precautions
to Prevent Sexual
Assaults and Other
Safety Incidents, but
Serious Weaknesses
Were Observed at
Selected Facilities
The residential programs and inpatient mental health units at the five VA
medical facilities we visited reported using several types of patientoriented and physical precautions to prevent safety incidents, such as
sexual assaults, from occurring in their programs. Patient-oriented
precautions included the use of flags on veterans’ electronic medical
records to notify staff of individuals who may pose threats to the safety of
others, and increased levels of observation for those veterans whom the
clinicians believe may pose risks to others. Physical precautions in
medical facilities we visited included monitoring precautions used to
observe patients, security precautions used to physically secure facilities
and alert staff of problems, and staff awareness and preparedness
precautions used to educate staff about security issues and provide police
assistance. However, at the facilities we visited, we found serious
deficiencies in the use and implementation of certain physical security
precautions, such as alarm system malfunctions and monitoring of
security cameras.
44
VA/DOD Clinical Practice Guideline for the Management of Post-Traumatic Stress
(October 2010) and 2010 Standards for Behavioral Health Care (2010).
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GAO-11-530 Safety in VA Medical Facilities
Several Types of PatientOriented Precautions Are
Used by Residential
Programs and Inpatient
Mental Health Units to
Prevent Sexual Assaults
and Other Safety Incidents
Staff from the residential programs and inpatient mental health units at the
five VA medical facilities we visited reported using several types of
patient-oriented precautions—techniques that focus on the patients
themselves as opposed to the physical features of clinical areas—to
prevent safety incidents from occurring in their programs. Generally, these
precautions were not specifically geared toward preventing sexual
assaults, but were used to prevent a broad range of safety incidents,
including sexual assaults. We found that some precautions were used by
staff in both residential programs and inpatient mental health units, while
other precautions were specific to only one of these settings. Some of the
patient-oriented precautions we noted during our site visits included the
following:
•
Using patient medical record flags. Staff in residential programs and
inpatient mental health units reported that they can request that an
electronic flag be placed on a veteran’s medical record when they have
concerns about the individual’s behavior and reported that they use these
flags to help inform their interactions with veterans. 45
•
Relocating or separating veterans. Staff in residential programs and
inpatient mental health units noted that they may move or separate
patients who have the potential for conflict with other veterans to help
prevent incidents from occurring. For example, at one medical facility we
visited such relocations involved moving veterans that the clinical staff
determine are safety risks to rooms closer to the nurses’ station where
they can be monitored more closely. Staff from some of the medical
facilities we visited reported that veterans who pose a threat to others may
also be moved to areas where they have restricted contact with others in
the unit.
•
Setting expectations and using patient contracts. Residential program staff
reported using several contract or patient education mechanisms to
reinforce both what is expected of veterans in these programs and what
behaviors are prohibited during their stay. For example, at one medical
45
VHA facilities may place an alert on a veteran’s electronic medical record to notify
employees that the veteran may pose a threat to the safety of other patients or employees.
According to VHA, these flags are to be used very judiciously and must be approved by
either appropriate local or VHA authorities. See VHA Directive 2010-053, Patient Record
Flags (Dec. 3, 2010). At each of the medical facilities we reviewed, requests for the
placement of medical record flags were formally reviewed by a multidisciplinary facility
committee responsible for activities related to the management of disruptive behavior at
the facility.
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GAO-11-530 Safety in VA Medical Facilities
facility we visited veterans signed treatment agreements noting that actual
violence, threats of violence, sexual harassment, and other actions were
not permitted and could result in discharge from the program. At another
medical facility we visited, patients signed a form agreeing to the
program’s policy that any form of physical contact, such as grabbing,
hugging, or kissing another person, was grounds for discharge from the
program.
•
Increasing direct patient observation. Staff in inpatient mental health units
we visited reported using increased levels of direct patient observation to
help prevent safety incidents. For example, two medical facilities we
visited used graduated levels of observation for veterans who they felt
posed safety risks or who were particularly vulnerable. These medical
facilities included all women veterans on the unit in these more frequent
staff check-ins to help ensure their safety and prevent incidents from
occurring. In addition, staff from one inpatient mental health unit we
visited placed a long-term mental health patient with a tendency of
inappropriately touching staff and patients on permanent one-to-one
observation status after several sexual assault incidents occurred.
The Types of Physical
Precautions in Use to
Prevent Sexual Assaults
and Other Safety Incidents
Vary among VA Medical
Facilities
VA medical facilities we visited employed a variety of physical security
precautions to prevent safety incidents in their residential programs and
inpatient mental health units. Typically, medical facilities had discretion to
implement these precautions based on the needs of their local medical
facility within broad VA guidelines. As a result, the types of physical
security precautions used in the five medical facilities we visited varied.
Several Types of Physical
Security Precautions Are in
Place in Selected Medical
Facilities
In general, physical security precautions were used to prevent a broad
range of safety incidents, including sexual assaults, but were not targeted
toward the prevention of sexual assaults only. We classified these
precautions into three broad categories: monitoring precautions, security
precautions, and staff awareness and preparedness precautions (see
table 4).
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GAO-11-530 Safety in VA Medical Facilities
Table 4: Physical Security Precautions in Residential Programs and Inpatient Mental Health Units at Selected VA Medical
Facilities
Monitoring precautions
•
Closed-circuit surveillance camera
use and monitoring
•
Unit rounds by VA staff
Security precautions
•
Locks and alarms at entrance and exit
access points
•
Locks and alarms for patient bedrooms and
bathrooms
•
Stationary, computer-based, and portable
personal panic alarms
•
Separate or specially designated areas for
women veterans
Staff awareness and preparedness
precautions
•
Staff training
•
VA police presence on units
•
VA police staffing and command
and control operations
Source: GAO.
Note: Physical security precautions varied by VA medical facility and program and were not
necessarily in place at all VA medical facilities and programs we visited.
•
Monitoring precautions—were those designed to observe and track
patients and activities in residential and inpatient settings. For example, at
some VA medical facilities we visited closed-circuit surveillance cameras
were installed to allow VA staff to monitor areas and to help detect
potentially threatening behavior or safety incidents as they occur. Cameras
were also used to passively document any incidents that occurred. Staff in
all the units we visited also conducted periodic rounds of the unit, which
involved staff walking through the program areas to monitor patients and
activities, either at regular intervals or on an as-needed basis.
•
Security precautions—were those designed to maintain a secure
environment for patients and staff within residential programs and
inpatient mental health units and allow staff to call for help in case of any
problems. For example, the units we visited regularly used locks and
alarms at entrance and exit access points, as well as locks and alarms for
some patient bedrooms. Another security precaution we observed was the
use of stationary, computer-based, and portable personal panic alarms for
staff. 46 Finally, we observed that some of the programs we visited had
established separate bedrooms, bathrooms, or other areas for women
veterans, or had placed women veterans in designated locations within the
units for security purposes.
46
Stationary panic alarms are fixed to furniture, walls, or other stationary items and can be
used to alert VA staff of a problem or call for help if staff feel threatened. Computer-based
panic alarms are activated by depressing a specified combination of keys on a medical
center keyboard. Portable personal panic alarms are small devices that staff can carry with
them while on duty that can also alert VA staff of a problem if activated.
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GAO-11-530 Safety in VA Medical Facilities
•
Selected VA Medical Facilities
Varied in Their Implementation
of Physical Security
Precautions
Staff awareness and preparedness precautions—were those designed to
both educate residential program and inpatient mental health unit staff
about, and prepare them to deal with, security issues and to provide police
support and assistance when needed. For example, the medical facilities
we visited regularly required training for staff on the prevention and
management of disruptive behavior. Another preparedness precaution in
use in some units was the establishment of a regular VA police presence
through activities such as police conducting rounds or holding educational
meetings with patients. Finally, all medical facilities we visited had a
functioning police command and control center, which program staff
could contact for police support when needed.
We found that the VA medical facilities we visited implemented physical
security precautions in a variety of ways. These precautions varied not
only by medical facility, but also among residential and inpatient settings.
Using broad VA guidelines, the medical facilities we visited generally
determined which type of physical precautions would best meet the needs
,
of their units and populations. 47 48 As a result, we found that some
precautions were used by all five medical facilities we visited, while others
were in place in only some of these medical facilities.
Inpatient mental health units. Physical security precautions in place at
all five medical facilities we visited included the use of regular staff rounds
to observe patients and clinical areas, locked unit entrances to prevent
entry by unauthorized individuals, and stationary or computer-based panic
alarm systems. Further, all units we visited used some combination of
stationary or computer-based panic alarms, safety whistles staff could
carry with them while on duty, and mandatory training on preventing and
managing disruptive behavior.
47
VA guidelines regarding physical security precautions for residential programs are
outlined in the VHA Mental Health RRTP Handbook. Monitoring precautions required by
this handbook include the use of closed-circuit surveillance cameras to monitor residential
program entrances, exits, and common areas, as well as requiring staff to conduct regular
rounds of program facilities. Security precautions required by this handbook include the
implementation of keyless entry for all residential programs, except CWT/TRs, and the
availability of locks on all bedrooms used by women veterans.
48
VA guidelines for physical security precautions for inpatient mental health units are
communicated as part of the Mental Health Environment of Care process. During
environment of care rounds, a multidisciplinary team of facility staff check to ensure that
inpatient mental health units are in compliance with a variety of VA policies, including
policies to regularly test panic alarm systems on these units and ensure that nursing
stations are safe for staff working in inpatient mental health unit settings.
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GAO-11-530 Safety in VA Medical Facilities
Some of these precautions used at all five medical facilities’ inpatient
mental health units were implemented in different ways across those
units. For example, while all inpatient mental health units used some type
of panic alarm system, the specific system in use within each unit varied;
some units used stationary panic alarm buttons fixed to walls or desks,
while others used a computer-based system in which staff would press
two keys simultaneously on their computers to trigger the alarm. The
inpatient mental health units also varied with respect to where their
stationary panic alarms sounded. At three medical facilities, the inpatient
units’ stationary or computer-based panic alarms sounded at the medical
facility’s police command and control center. At another medical facility,
two types of panic alarms were used. The stationary panic alarms used by
this facility’s inpatient mental health units sounded at both the police
command and control center and on the inpatient unit itself to instantly
alert unit staff members if a panic alarm was depressed, while the
computer-based panic alarms used at the nursing stations sounded only at
the police command and control center. Alarms in use at the fifth medical
facility we visited sounded at the units’ nursing stations. Finally, while all
five units had locked entrances, four of the units used physical keys to
open the locks on the entrance doors, while the unit at the fifth medical
facility used a keyless entry approach in which staff used their badges to
electronically enter the units and relied on physical keys only if the
keyless system was not functioning.
Other precautions were present in only some of the inpatient mental
health units we visited. For example, three medical facilities used closedcircuit surveillance cameras on their inpatient units to varying degrees.
Cameras in place at one of these medical facilities could be monitored at
the unit’s nursing station and were used to monitor the entrance doors,
common areas, and seclusion rooms used for veterans who needed to be
isolated from others. At another medical facility, cameras were used in a
similar fashion, except that this unit did not use cameras to monitor
veterans in seclusion rooms. Cameras in place at the remaining medical
facility were part of a passive system that was not actively monitored by
staff at the unit’s nursing station and was used only to record incidents at
the entrance doors and common areas. One of these medical facilities also
used alarms on bedroom doors that enunciated when the door was
opened. These door alarms were installed on all bedrooms used by women
and for other veterans on an as-needed basis. The ability to instantly alert
staff of either unexpected entries or exits from these rooms could
potentially minimize response time if an incident occurred. This latter
medical facility also used a community policing approach, with one VA
police officer dedicated to meeting regularly with inpatient mental health
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GAO-11-530 Safety in VA Medical Facilities
unit staff and patients to build relationships and help address any issues or
concerns that arose. 49
Residential programs. Physical security precautions in place at all five
medical facilities’ non-CWT/TR residential programs included the use of
regular staff rounds to observe patients, staff training on the prevention
and management of disruptive behavior, the use of surveillance cameras to
monitor program areas, and the placement of women veterans in
designated areas of the residential facility. Some of these commonly used
precautions were implemented in different ways across the five medical
facilities. For example, some medical facilities placed women veterans in
separate bedrooms located closest to the nursing stations, while others
placed only women veterans in a separate wing of the facility. Medical
facilities’ residential programs also varied with respect to where their
closed-circuit camera feeds could be viewed. At four of the five medical
facilities we visited, the camera feeds could be viewed by staff at the
programs’ nursing stations or security desks, but at two medical facilities,
cameras at the domiciliary could also be viewed by staff at VA police
command and control centers. At all medical facilities, the camera systems
were passive and not actively monitored by staff.
Other precautions were used only in some of the five medical facilities’
non-CWT/TR residential programs. For example, residential programs in
four of five medical facilities used stationary or computer-based panic
alarms to alert others in case of emergency; the remaining medical facility
did not use any form of stationary or computer-based panic alarm system.
The four medical facilities’ stationary alarms varied with respect to where
they sounded. In addition, only one medical facility we visited provided
portable personal panic alarms with GPS capability to its residential
program staff. In addition, VA police presence was widely used in two of
the five medical facilities we visited. One of these medical facilities
permanently staffed VA police officers at a residential program located off
the medical facility’s main campus, while the other medical facility’s
community policing officer met regularly with residential program staff
and patients to facilitate more direct communications between the
programs and VA police at the medical facility.
49
This officer also worked with VA staff at other locations in the facility, not just with staff
of the inpatient mental health unit.
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GAO-11-530 Safety in VA Medical Facilities
CWT/TR residential programs. The three CWT/TR residential programs
we visited used several types of physical security precautions. 50 For
example, two of the three CWT/TR programs we visited used closedcircuit surveillance cameras; one medical facility used surveillance
cameras to record activity at entrances and exits, while another medical
facility used surveillance cameras to record the parking lot areas. Neither
of these locations actively monitored the camera feeds. In addition, one
medical facility reported using regular rounds and conducting bed checks.
Another medical facility had individual locks on bedroom doors; other
sites did not. 51 Only one of the three CWT/TR programs we visited
accepted women; its apartment-style structure allowed women veterans to
be placed in separate apartments. The other two CWT/TRs did not provide
services for women veterans due to safety and privacy concerns stemming
from their single-family home structures.
Significant Weaknesses
Existed in the Use and
Implementation of Certain
Physical Security
Precautions at Selected VA
Medical Facilities
During our review of the physical security precautions in use at the five VA
medical facilities we visited, we observed seven weaknesses in three
areas. 52 These weaknesses included malfunctions in stationary and
portable personal panic alarm systems, inadequate monitoring of security
cameras, and insufficient staffing of police and security personnel (see
table 5).
50
Two of the medical facilities we visited did not have a CWT/TR program.
51
At one site, VA staff reported that this was because local fire officials had informed them
that interior locks were a safety issue.
52
Our review of physical security precautions at the five VA medical facilities we visited
was limited to the residential programs, inpatient mental health units, and medical facility
command and control centers.
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GAO-11-530 Safety in VA Medical Facilities
Table 5: Weaknesses in Physical Security Precautions in Residential Programs and Inpatient Mental Health Units at Selected
VA Medical Facilities
Monitoring precautions
•
Inadequate monitoring of closedcircuit surveillance cameras
Staff awareness and preparedness
precautions
Security precautions
•
Alarm malfunctions of stationary, computer•
VA police staffing and workload
based, and personal panic alarms
challenges
•
Inadequate documentation or review of alarm •
Lack of stakeholder involvement in
testing
unit redesign efforts
•
Failure of alarms to alert both unit staff and
VA police
•
Limited use of personal panic alarms
Source: GAO.
Inadequate monitoring of closed-circuit surveillance cameras. We
observed that VA staff in the police command and control center were not
continuously monitoring closed-circuit surveillance cameras at all five VA
medical facilities we visited. For example, at one medical facility, the
system used by the residential programs at that medical facility cannot be
monitored by the police command and control center staff because it is
incompatible with systems installed in other parts of the medical facility.
According to this medical facility’s VA police, the residential program staff
did not consult with VA police before installing their own system. At
another medical facility where staff in the police office monitor cameras
covering the residential programs’ grounds and parking area, we found
that the police office was unattended part of the time. In addition, at the
remaining three medical facilities we visited, staff in the police command
and control centers assigned to monitor medical facility surveillance
cameras had other duties that prevented them from continuously
monitoring the camera feeds. Specifically, they were also responsible for
serving as telephone operators and police/emergency dispatchers for the
entire VA medical facility. During our direct observations of their
activities, we noted that they were not monitoring the camera feeds
continuously. 53 Although effective use of surveillance camera systems
cannot necessarily prevent safety incidents from occurring, lapses in
monitoring by security staff compromise the effectiveness of these
systems in place to help prevent or lessen the severity of safety incidents.
53
At some facilities, just one person was assigned to serve both functions, while at another
location two people were expected to share those functions but only one person was
present at the time of our visit due to staffing vacancies, illness, or shortages.
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Alarm malfunctions. At least one form of alarm failed to work properly
when tested at four of the five medical facilities we visited. For example,
at one medical facility, we tested the portable personal panic alarms used
by residential program staff and found that the police command and
control center could not always properly pinpoint the location of the tester
when an alarm was activated. When we tested this alarm inside a building
at this campus it functioned properly; however, when we tested it outside,
the location identified as the site of the alarm was at least 100 feet away
from the location where we set off the alarm. Further, when we tested an
emergency call box located outside the entrance to the residential
program buildings at this same medical facility, the call went to a central
telephone operator at the VA medical facility switchboard—not the VA
police command and control center—and the system improperly identified
our tester as calling from an elevator rather than from our location outside
the residential program building. At another medical facility that used
stationary panic alarms in inpatient mental health units, residential
programs, and other clinical settings (i.e., staff offices, nursing stations,
and common rooms), almost 20 percent of these alarms throughout the
medical facility were inoperable. Many of the inoperable alarms were due
to ongoing construction of new units at the medical facility, but some of
the remaining inoperable alarms were located in other parts of the medical
facility still in use. It is unclear if staff in these other areas were aware that
these alarms were inoperable and could not be used to call for help if they
needed it. At an inpatient mental health unit in a third medical facility, our
tests of the computer-based panic alarm system detected multiple alarm
failures. Specifically, three of the alarms we tested failed to properly
pinpoint the location of our tester because the medical facility’s computers
had been moved to different locations and were not properly reconfigured.
Finally, at a fourth medical facility, alarms we tested in the inpatient
mental health unit sounded properly, but staff in the unit and VA police
responsible for testing these alarms did not know how to turn them off
after they were activated. In each of the cases where alarms
malfunctioned, VA staff were not aware the alarms were not functioning
properly until we informed them. Deficiencies like these at VA medical
facilities could lead to delayed response times and seriously erode efforts
to prevent or mitigate sexual assaults and other safety incidents.
Inadequate documentation or review of alarm system testing. We
found that one of the five sites we visited failed to properly document tests
conducted of their alarm systems for their residential programs, although
testing of alarms is a required element in VA’s Environment of Care
Checklist. Testing of alarm systems is important to ensure that systems
function properly, and not having complete documentation of alarm
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GAO-11-530 Safety in VA Medical Facilities
system testing is an indication that periodic testing may not be occurring.
In addition, three medical facilities reported using computer-based panic
alarms that are designed to be self-monitoring to identify cases where
computers equipped with the system fail to connect with the servers
monitoring the alarms. All three of these medical facilities stated that due
to the self-monitoring nature of these alarms, they did not maintain alarm
test logs of these systems. However, we found that at two of these three
medical facilities these alarms failed to properly alert VA police when
tested. Such alarm system failures indicate that the self-monitoring
systems may not be effectively alerting medical facility staff of alarm
malfunctions when they occur, indicating the need for these systems to be
periodically tested by VA police.
Alarms failed to alert both police and unit staff. In inpatient mental
health units at all five medical facilities we visited, stationary and
computer-based panic alarm systems we tested did not alert staff in both
the VA police command and control center and the inpatient mental health
unit where the alarm was triggered. Alerting both locations is important to
better ensure that timely and proper assistance is provided. At four of
these medical facilities, the inpatient mental health units’ stationary or
computer-based panic alarms notified the police command and control
centers but not staff at the nursing stations of the units where the alarms
originated. Had these alarms been used in real emergencies, response
times may have been delayed because staff in the police command and
control center would have had to inform the inpatient mental health unit
that an alarm had been activated by someone within their unit. At the fifth
medical facility, the stationary panic alarms only notified staff in the unit
nursing station, making it necessary to separately notify the VA police.
Finally, none of the stationary or computer-based panic alarms used by
residential programs notified both the police command and control
centers and staff within the residential program buildings when tested. 54
Limited use of portable personal panic alarms. Electronic portable
personal panic alarms were not available for the staff at any of the
inpatient mental health units we visited and were available to staff at only
one residential program we reviewed. In two of the inpatient mental health
units we visited, staff were given safety whistles they could use to signal
others in cases of emergency, personal distress, or concern about veteran
54
One of the residential programs we reviewed did not use stationary panic alarm systems.
This facility relied on portable personal panic alarms for its residential program staff.
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GAO-11-530 Safety in VA Medical Facilities
or staff safety. However, relying on whistles to signal such incidents may
not be effective, especially when staff members are the victims of assault.
For example, a nurse at one medical facility we visited was involved in an
incident in which a patient grabbed her by the throat and she was unable
to use her whistle to summon assistance. Some inpatient mental health
unit staff we spoke with indicated an interest in having portable personal
panic alarms to better protect them in situations like these.
VA police staffing and workload challenges. At most medical facilities
we visited, VA police forces and police command and control centers were
understaffed, according to medical facility officials. For example, during
our visit to one medical facility, VA police officials reported being able to
staff just two officers per 12-hour shift to patrol and respond to incidents
at both the medical facility and at a nearby 675-acre veteran’s cemetery.
While this staffing ratio met the minimum standards for VA police staffing,
having only two police officers to cover such a large area could potentially
increase the response times should a panic alarm activate or other security
incident occur on medical facility grounds. Also, we found that there was
an inadequate number of officers and staff at this medical facility to
effectively police the medical facility and maintain a productive police
force. The medical facility had a total of nine police officers at the time of
our visit; according to VA staffing guidance, the minimum staffing level for
this medical center should have been 19 officers. Similarly, at another
medical facility, the police force was short 14 active police officers
because some officers either were on military leave or awaiting the
completion of pending background checks. 55 During our visit to this
medical facility, we also noted a shortage of officers at one of the medical
facility’s police offices responsible for the inpatient mental health units.
Because of this, there were periods of time when this police office was
unattended. Not all medical facilities we visited had staffing problems. At
one medical facility, the VA police appeared to be well staffed and were
even able to designate staff to monitor off-site residential programs and
community based outpatient clinics.
Lack of stakeholder involvement in unit redesign. As medical
facilities undergo remodeling, it is important that stakeholders are
consulted in the design process to better ensure that new or remodeled
areas are both functional and safe. Involving the VA police, security
55
The VA police chief for this facility reported having adequate staff coverage despite these
staffing limitations.
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GAO-11-530 Safety in VA Medical Facilities
specialists, computer experts, and staff in the affected units would better
ensure that proper security precautions are built into redesign projects.
We found that such stakeholder involvement on remodeling projects had
not occurred at one of the medical facilities we visited. At this medical
facility, some clinicians said that a lack of stakeholder involvement in the
redesign of the inpatient mental health units had created several safety
concerns and that postconstruction changes had to be made to the unit to
ensure the safety of veterans and unit staff. Specifically, clinical and VA
police personnel were not consulted about a redesign project for the
inpatient mental health unit. The new unit initially included one nursing
station that did not prevent patient access if necessary. After the unit was
reopened following the renovation, there were a number of assaults,
including an incident where a veteran reached over the counter of the
unit’s nursing station and physically assaulted a nurse by stabbing her in
the neck, shoulder, and leg with a pen. Had staff been consulted on the
redesign of this unit, their experience managing veterans in an inpatient
mental health unit environment would have been helpful in developing
several safety aspects of this new unit, including the design of the nursing
station. Less than a year after opening this unit, medical facility leadership
called for a review of the units’ design following several reported
incidents. As a result of this review, the unit was split into two separate
units with different veteran populations, an additional nursing station was
installed, and changes were planned for the structure of both the original
and newly created nursing stations—including the installation of a new
shoulder-height plexiglass barricade on both nursing station counters.
Conclusions
VA management has not remedied problems relating to the reporting of
sexual assault incidents, the assessment of sexual assault-related risks,
and the precautions used to prevent sexual assaults and other safety
incidents in VA medical facilities. This has led to a disorganized incident
reporting structure and has left VA vulnerable to the continued occurrence
of such incidents and unable to take systematic action on needed
improvements to prevent future incidents in all VA medical facilities. To
mitigate the occurrence of sexual assaults and other safety incidents in its
medical facilities and better ensure the safety of both veterans and staff,
VA needs to address several areas—including the processes for reporting
sexual assault incidents, the underreporting of sexual assault incidents,
the assessment of risks certain veterans may pose to the safety of others,
and the implementation of physical security precautions. Failure to act
decisively in all of these areas would likely continue to place veterans and
medical facility staff in some locations in harm’s way. To begin addressing
these concerns, VA must ensure that both management and law
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enforcement officials are aware of the volume and specific types of sexual
assault incidents that are reported through the law enforcement stream.
Such awareness would help both management and law enforcement
officials address safety concerns that emerge for both patients and staff
throughout VA’s health care system.
Medical facility staff remain uncertain about what types of incidents
should be reported to VHA leadership and VA law enforcement officials,
and prevention and remediation efforts are eroded by failing to tap the
expertise of these officials. These officials can offer valuable suggestions
for preventing and mitigating future sexual assault incidents and help
address broader safety concerns through systemwide improvements
throughout the VA healthcare system. Leaving reporting decisions to local
VA medical facilities—rather than allowing VHA management and VA OIG
officials to determine what types of incidents should be reported based on
the consistent application of known criteria—increases the risk that some
sexual assault incidents may go unreported. Moreover, uncertainty about
sexual assault incident reporting is compounded by VA not having:
(1) established a consistent definition of sexual assault, (2) set clear
expectations for the types of sexual assault incidents that should be
reported to VISN and VHA Central Office leadership officials, and
(3) maintained proper oversight of sexual assault incidents that occurred
in VA medical facilities. Unless these three key features are in place, VHA
will not be able to ensure that all sexual assault incidents will be
consistently reported throughout the VA health care system. Specifically,
the absence of a centralized tracking system to monitor sexual assault
incidents across VA medical facilities may seriously limit efforts to both
prevent such incidents in the short and long term and maintain a working
knowledge of past incidents and efforts to address them when staff
transitions occur.
Maintaining veterans’ access to care is a priority in VA, but in those cases
where veterans have a history of sexual assault or other violent acts, VA
must be vigilant in identifying the risks that such veterans may pose to the
safety of others at its medical facilities. Risk assessment tools can be
valuable mechanisms for identifying those veterans that pose risks to
others while being treated at VA medical facilities. However, VA does not
currently have a risk assessment tool specific to sexual assault and instead
relies on clinicians’ professional judgments. These judgments are largely
informed by the assessment of veterans’ legal histories, which depend
heavily on self-reported data that must be accurately documented by
clinicians in veterans’ medical records. Moreover, current VA guidance is
not specific about the extent to which current and past legal issues—such
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as the type or date of convictions—should be documented in veterans’
medical records—a factor that further complicates the ability of VA
clinicians both to compile complete legal histories on veterans and to
make informed decisions about risks certain veterans may pose to other
veterans and VA staff.
Ensuring that medical facilities maintain a safe and secure environment
for veterans and staff in residential programs and inpatient mental health
units is critical and requires commitment from all levels of VA. Currently,
the five VA medical facilities we visited are not adequately monitoring
surveillance camera systems, maintaining the integrity of alarm systems,
and ensuring an adequate police presence. Closer oversight by both VISNs
and VA and VHA Central Office staff is needed to provide a safe and secure
environment throughout all VA medical facilities.
Recommendations for
Executive Action
To improve VA’s reporting and monitoring of allegations of sexual assault,
we recommend that the Secretary of Veterans Affairs direct the Under
Secretary for Health to take the following four actions:
•
Ensure that a consistent definition of sexual assault is used for reporting
purposes by all medical facilities throughout the system to ensure that
consistent information on these incidents is reported from medical
facilities through VISNs to VHA Central Office leadership.
•
Clarify expectations about what information related to sexual assault
incidents should be reported to and communicated within VISN and VHA
Central Office leadership teams, such as officials responsible for
residential programs and inpatient mental health units.
•
Implement a centralized tracking mechanism that would allow sexual
assault incidents to be consistently monitored by VHA Central Office staff.
•
Develop an automated mechanism within the centralized VA police
reporting system that signals VA police officers to refer cases involving
potential felonies, such as rape allegations, to the VA OIG to facilitate
increased communication and partnership between these two entities.
To help identify risks and address vulnerabilities in physical security
precautions at VA medical facilities, we recommend that the Secretary of
Veterans Affairs direct the Under Secretary for Health to take the
following four actions:
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Agency Comments
and Our Evaluation
•
Establish guidance specifying what should be included in legal history
discussions with veterans and how this information should be documented
in veterans’ biopsychosocial assessments.
•
Ensure medical centers determine whether existing stationary, computerbased, and portable personal panic alarm systems operate effectively
through mandatory regular testing.
•
Ensure that alarm systems effectively notify relevant staff in both medical
facilities’ VA police command and control centers and unit nursing
stations.
•
Require relevant medical center stakeholders to coordinate and consult on
(1) plans for new and renovated units, and (2) any changes to physical
security features, such as closed-circuit television cameras.
VA provided written comments on a draft of this report, which we have
reprinted in appendix III. In its comments, VA generally agreed with our
conclusions, concurred with our recommendations, and described the
agency’s plans to implement each of our recommendations. VA also
provided technical comments which we have incorporated as appropriate.
Specifically, VA outlined its plan to create a multidisciplinary workgroup
that will undertake efforts to respond to seven of our eight
recommendations—including developing definitions of sexual assault and
other safety incidents, reviewing existing data sources and communication
mechanisms, developing a centralized mechanism for monitoring sexual
assaults and other safety incidents, and developing risk assessment and
management guidance. The workgroup will be co-chaired by the Acting
Assistant Deputy Under Secretary for Health for Clinical Operations and
the Chief Consultant for the Women Veterans Health Strategic Health Care
Group. Participants will include representatives from VA field operations
and the following offices: (1) the VHA Deputy Under Secretary for Health
for Operations and Management; (2) the VHA Deputy Under Secretary for
Health for Policy and Services; (3) the VHA Principal Deputy Under
Secretary for Health; (4) the VA Office of Security and Law Enforcement;
and (5) other offices as needed, including the VA Office of General
Counsel.
As outlined by VA, the workgroup will review current data sources, the
organization and structure of VHA’s methods for reporting sexual assaults
and other safety incidents, and the agency’s current response to sexual
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assault incidents. In addition, the workgroup will review and evaluate
risks and efforts to prevent sexual assaults. Finally, the workgroup will
assess the status of current policies within VHA and address which
organizational initiatives and policies should be updated. According to
VA’s comments, the workgroup will provide the Under Secretary for
Health and his Deputies with monthly verbal updates on its progress, as
well as an initial action plan by July 15, 2011 and a final report by
September 30, 2011.
In addition, VA stated in its comments that the Office of the Deputy Under
Secretary for Health for Operations and Management will work in
conjunction with this multidisciplinary workgroup on a number of
initiatives to address panic alarm system testing and coordination on
renovation and construction at VA medical facilities. Initiatives described
in VA’s comments specifically included efforts to: (1) re-emphasize the
need for routine testing of panic alarm systems; (2) examine existing VHA
policy to determine if revisions are needed to ensure that regular testing of
alarm systems is required and preventative maintenance is performed on
these systems; (3) re-emphasize the importance of coordination at the
local level to ensure that safety and security are considered during
construction and renovation processes at local levels; and (4) determine
how such coordination can be formalized as part of the planning and
design processes for all construction processes in conjunction with the VA
Office of Construction.
Finally, to address our remaining recommendation, the VA OSLE will
develop a mechanism that will directly prompt VA police officers to report
potential felonies, including rape, to the VA OIG when these offenses are
recorded in the centralized police reporting system. In its comments, VA
stated that this system will also send a message to a specialized mailbox
alerting VA OIG investigators that a potential felony has been recorded in
the centralized police reporting system.
We are sending copies of this report to the Secretary of Veterans Affairs,
appropriate congressional committees, and other interested parties. In
addition, the report is available at no charge on the GAO Web site at
http://www.gao.gov.
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GAO-11-530 Safety in VA Medical Facilities
If you or your staffs have any questions about this report, please contact
me at (202) 512-7114 or at [email protected]. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on the
last page of this report. GAO staff who made major contributions to this
report are listed in appendix IV.
Randall B. Williamson
Director, Health Care
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GAO-11-530 Safety in VA Medical Facilities
Appendix I: Scope and Methodology
Appendix I: Scope and Methodology
This appendix describes the information and methods we used to
examine: (1) VA’s processes for reporting sexual assault incidents and the
volume of these incidents reported in recent years; (2) the extent to which
sexual assault incidents are fully reported and what factors may contribute
to any observed underreporting; (3) how medical facility staff determine
sexual assault-related risks veterans may pose in residential and inpatient
mental health settings; and (4) the precautions in place in residential and
inpatient mental health settings to prevent sexual assaults and other safety
incidents and any weaknesses in these precautions.
Specifically, we discuss our methods for selecting VA medical facilities for
site visits; identifying appropriate Department of Veterans Affairs (VA) and
Veterans Health Administration (VHA) Central Office officials to interview;
assessing the extent to which sexual assault incidents are fully reported;
determining what legal history information is captured in veterans’
medical records; and examining the physical security precautions in use in
selected residential programs and inpatient mental health units. In
addition to the methods described below, we also reviewed relevant VA
and VHA policies, handbooks, directives, and other guidance documents
to inform our overall review of these issues whenever possible.
Site Selection
Methodology and
Interviews with Medical
Facility Officials
We conducted five site visits to VA medical facilities to obtain the
perspectives of medical facility level officials and clinicians working in
residential programs and inpatient mental health units and to observe the
types of physical security precautions used within these medical facilities.
To identify VA medical facilities for our site visits, we examined available
VA and medical facility level information to ensure our sample included
medical facilities with the following characteristics:
•
Presence of both residential programs and inpatient mental health units.
We identified medical facilities that had both types of programs by
consulting VA documentation of residential program and inpatient mental
health units.
•
Presence of a variety of residential program specialties. We identified
medical facilities that had: (1) at least one residential program—including
domiciliaries and residential rehabilitation treatment programs (RRTP)—
and (2) had a compensated work therapy/transitional residence (CWT/TR)
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Appendix I: Scope and Methodology
program wherever possible. 1 In addition, we selected medical facilities
that had a variety of RRTP program specialties designed to treat particular
mental health issues, such as post-traumatic stress disorder (PTSD) and
substance abuse.
•
Various levels of experience reporting sexual assault incidents. Using
sexual assault case files provided by the VA Office of Inspector General
(OIG) Office of Investigations—Criminal Investigations Division—we
identified VA medical facilities with a wide variety of experiences
reporting sexual assault incidents, including one medical facility with no
reported sexual assault incidents and several others that had reported a
number of sexual assault incidents that occurred within their residential
programs or inpatient mental health programs. This ensured that the VA
medical facilities we visited captured a range of perspectives on the
reporting of sexual assault incidents.
•
Various medical facility sizes. We identified medical facilities with
different campus sizes and types of on-site programs by determining
whether each medical facility was a single or multisite medical facility and
considering several other aspects of medical facility design, such as the
presence of on-site day care centers.
Using these criteria, we judgmentally selected five VA medical facilities to
visit during our field work. During our site visits to these locations, we
interviewed each medical facility’s leadership team; residential program
and inpatient mental health unit managers and staff; VA police; quality and
patient safety managers; disruptive behavior committee members; woman
veterans program manager; military sexual trauma program coordinator;
and veterans justice outreach program coordinator. We spoke with these
officials about a variety of topics, including incident reporting, risk
assessment practices, and precautions used to prevent safety incidents,
including sexual assaults.
In addition, we spoke with officials from the four Veterans Integrated
Service Networks (VISN) responsible for managing these medical facilities
to discuss their expectations, policies, and procedures for reporting sexual
assault incidents. We also spoke with each VISN’s Health Care for Re-entry
Veterans program managers to gain additional insight on these programs.
1
As CWT/TR programs are located in fewer locations than the other programs, not all
medical facilities we selected had these programs.
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GAO-11-530 Safety in VA Medical Facilities
Appendix I: Scope and Methodology
Information obtained from our visits to selected VA medical facilities and
interviews with selected VISNs cannot be generalized to all VISNs and VA
medical facilities throughout the nation.
Interviews with VA and
VHA Central Office
Officials
We also interviewed VA and VHA Central Office officials responsible for
incident reporting; law enforcement oversight; mental health programs;
women veterans; risk assessment; patient privacy; and legal issues. We
spoke with the following offices at the department level within VA:
(1) Office of Security and Law Enforcement (OSLE); (2) the Integrated
Operations Center (IOC); (3) the Office of General Counsel; and (4) the
OIG’s Office of Investigations—Criminal Investigations Division. We also
interviewed officials from the following offices within VHA Central Office:
(1) the Office of the Deputy Under Secretary for Health for Operations and
Management; (2) the Office of the Principal Deputy Under Secretary for
Health; (3) the Office of Mental Health Services; (4) the Women Veterans
Health Strategic Health Care Group; and (5) the Information Access and
Privacy Office.
Analyses of Sexual Assault
Incident Reporting
To assess the effectiveness of the reporting of sexual assault
incidents, we reviewed documentation of sexual assault incidents
from VHA management officials and VA law enforcement entities.
Document Request and
Response
To analyze the reporting process for sexual assault incidents, we
requested documentation of these incidents from our selected VISNs;
VHA’s Office of the Deputy Under Secretary for Health for Operations and
Management; VA OSLE; and VA OIG. For all information we requested, we
asked VHA or VA officials to send us either issue briefs or investigation
documentation that fell within the definition of sexual assault used for the
purposes of this report. 2
2
For the purposes of this report, we define sexual assault as any type of sexual contact and
attempted sexual contact that occurs without the explicit consent of the recipient of the
unwanted sexual activity. Assaults may have involved psychological coercion, physical
force, or victims who could not consent due to mental illness or other factors. Falling
under this definition of sexual assault are sexual activities such as forced sexual
intercourse, sodomy, oral penetration or penetration using an object, molestation, fondling,
and attempted rape or sexual assault. This also included any threats of any of the above.
Victims of assault could be male or female. This did not include cases involving only
indecent exposure, exhibitionism, or sexual harassment.
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Appendix I: Scope and Methodology
To review reports submitted through VHA’s management reporting stream,
we requested copies of issue briefs on sexual assault incidents sent to our
selected VISNs and the VHA Office of the Deputy Under Secretary for
Health for Operations and Management. 3 We also asked our selected
VISNs to identify which of these issue briefs were sent to the VHA Central
Office for further review. The four VISNs responded that in total they
received
16 issue briefs and forwarded 11 of these documents to the VHA Central
Office. Due to limitations in how information is archived within VHA’s
Office of the Deputy Under Secretary for Health for Operations and
Management, we could not determine how many issue briefs this office
received through the management reporting stream across all VA medical
facilities. 4
To review reports submitted through VA’s law enforcement reporting
stream, we requested documentation of sexual assault incidents reported
to the VA police through the VA OSLE and documentation of incidents
referred to the VA OIG for investigation. From the VA OSLE, we requested
and received police files submitted by any VA medical facility related to
sexual assault incidents that occurred since January 2005. We then limited
the police files we reviewed to only those incidents that occurred between
January 2007 and July 2010 due to a records schedule that requires the VA
police to destroy files greater than 3 years old. 5 As a result of this
requirement, our review of sexual assaults reported to the VA police
during 2007 was limited to only those cases retained by VA police.
Additionally, due to the lack of a centralized VA police reporting system
prior to fiscal year 2009, VA medical facility police manually transmitted
all reports to the VA OSLE for inclusion in our review, which resulted in
3
Issue briefs are reports that briefly document specific factual information about incidents
and are used to notify officials of ongoing incidents occurring at VA facilities, including
sexual assault incidents. These documents are forwarded from the facility to the VISN and
can be sent forward to the VHA Central Office as needed.
4
VHA’s Office of the Deputy Under Secretary for Health for Operations and Management
did provide a response to our request for issue briefs but, due to the lack of a VHA
centralized archive of this information, officials from this office had to contact VISNs to
construct a sample of issue briefs they may have received during the time period of our
analysis. Therefore, this response did not provide an accurate sample of all issue briefs this
office had received and reviewed at the time these incidents were initially reported and
was not used in our analysis of the management reporting stream.
5
VA police are required to destroy files after 3 years under a records schedule approved by
the National Archives and Records Administration (NARA).
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Appendix I: Scope and Methodology
only those reports received by VA OSLE being included in our analysis. We
received a total of 520 VA police case files for the period January 2007
through July 2010, including both open and closed investigations, from the
VA OSLE. In addition, we requested copies of VA OIG investigation
documentation of sexual assault incidents that occurred in all VA medical
facilities from January 2005 through July 2010. However, we limited our
review of VA OIG investigation documentation to only those incidents that
occurred between January 2007 and July 2010 to ensure our review of VA
police cases and VA OIG investigations were concurrent. We received
investigation documentation on 106 closed sexual assault incidents that
occurred during this time frame from the VA OIG. Additionally, the VA OIG
reported that there were 9 incidents that were currently under
investigation at the time of our review and we did not require them to
provide documentation on these cases due to the sensitive nature of these
ongoing investigations.
Scoping of VA Police Case Files
and VA OIG Investigation
Documentation
To determine whether each of the incidents provided by the VA police and
the VA OIG should be included in our analysis of sexual assault incidents
that occurred in VA medical facilities between January 2007 and July 2010,
we reviewed whether each incident received from the VA police and the
VA OIG met the definition of sexual assault used for this engagement. To
complete this assessment, two analysts worked independently to make an
initial determination on whether each incident met this definition and a
third analyst reviewed these initial judgments to arbitrate a final decision
using predetermined decision rules. Of the 520 documents received from
the VA police during the specified time frame, 284 incidents were included
in our analysis, 222 were determined to be out of the scope of our review,
and the remaining 14 did not have enough information in the police files to
determine whether or not these cases fell within the scope of our review.
This process was repeated for the 106 VA OIG investigation documents for
closed investigations we received and 96 were included in our analysis, 7
were determined to be outside the scope of our review, and the remaining
3 did not contain enough information to determine whether or not they fell
within the scope of our review.
Our analyses of sexual assault incidents reported to the VA police and the
VA OIG was limited to only those incidents that were reported and cannot
be used to project the volume of sexual assault incident reports that may
occur in future years. Following verification that police and VA OIG
incidents met our definition of sexual assault and comparisons of the two
entities’ reported sexual assault incidents, we found data derived from
these reports to be sufficiently reliable for our purposes.
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Appendix I: Scope and Methodology
For our analysis of the 284 incidents reported to the VA police determined
to be within the scope of our review, we identified several key data points
in each case file, including the gender of the perpetrator and victim, the
relationship the perpetrator and victim had to VA, and the medical facility
location and VISN where the incident originated. In addition, we also
placed these incidents into one of five categories to analyze the volume of
several types of sexual assault incidents that occurred throughout VA
medical facilities.
Analysis of VA Police Case
Files
•
Inappropriate touch—included any case involving only allegations of
touching, fondling, grabbing, brushing, kissing, rubbing, or other liketerms.
•
Forced or inappropriate oral sex—included any case involving only
allegations of forced or inappropriate oral sex. 6
•
Forceful examination—included any case alleging only a medical
examination that was painful, uncomfortable, or seemingly inappropriate
to the patient.
•
Rape—included any case involving rape allegations, which we defined as
vaginal or anal penetration by any body part or object without consent. We
deemed a file as containing a rape allegation if any of the following were
noted within the file: (1) either the victim or VA staff used the term rape in
their descriptions of the incident; (2) a rape kit was requested or
administered; (3) allegations that sex occurred without consent, whether
or not penetration was described; or (4) allegations of attempted vaginal
or anal penetration without consent. 7 In addition, cases where VA staff
deemed that one or more of the victims involved were mentally incapable
of giving consent for sexual activities or that a victim’s ability to consent
was otherwise impaired, were included in this category.
•
Other—included any case that did not fit into the categories described
above or if the incident described in the police file was unclear. In
addition, cases involving consensual sexual activities between two
individuals who were in a mental health or geriatric unit where both
6
Inappropriate oral sex includes oral sex that may have been a consensual act between the
parties in question, but was deemed sexual assault by VA staff.
7
VA police coding of a case as rape was not sufficient to categorize a case as an rape
allegation for our purposes without also including at least one of the above criteria.
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GAO-11-530 Safety in VA Medical Facilities
Appendix I: Scope and Methodology
parties were found to be capable of giving consent were included in this
category.
VA OIG Reporting Analysis
To examine the discrepancies between the number of sexual assault
incidents reported to VA police and the number referred to the VA OIG, we
reviewed the 67 rape allegations that were reported to VA police to
determine which of these reports were referred to the VA OIG. We
selected rape allegations for this additional review due to the severity of
these allegations and the likelihood they would be considered potential
felonies that must be reported to the VA OIG. To complete this analysis,
we matched the VA police files containing rape allegations to a VA OIG
investigation document wherever possible. A police file and VA OIG
investigation document were considered a match when both documents
discussed the same incident details—including information such as
discussion of the same perpetrator and victim, medical facility, and
incident date. Of the 67 rape allegations reported to the VA police, 25 had a
matching VA OIG investigation document, while the remaining 42 did not. 8
In addition, we reviewed federal statutes related to sexual offenses and
sentencing classification for felonies to verify that all rape allegations
included in our review met the statutory criteria for felonies under federal
law. Finally, investigators from the VA OIG reviewed summaries of the 42
rape allegations that did not match VA OIG investigation documentation
previously provided to determine whether or not they would have
expected such cases to be reported to their office. These case summaries
did not contain identifying information about the suspects, victims, or VA
medical facilities involved in these incidents. 9 Four VA OIG investigators
reviewed these summaries and based their determinations on several key
factors developed from their experience as law enforcement officers.
Legal History Analysis of
Biopsychosocial
Assessments
We reviewed the biopsychosocial assessment sections of selected
veterans’ medical records to better understand how legal history
information contained in these documents could be used to inform
clinicians’ assessments of sexual assault-related risks veterans may pose
8
We did not require the VA OIG to provide documentation for 9 incidents currently under
investigation that occurred within the time period of our analysis. It is possible that some
of these ongoing investigations may be included in the 42 rape allegations we could not
match to VA OIG investigation documentation.
9
We did not provide these complete VA police case files to the VA OIG to protect the
privacy of those involved in the incident and the anonymity of the VA facilities and
investigating officers who did not refer these cases to the VA OIG.
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GAO-11-530 Safety in VA Medical Facilities
Appendix I: Scope and Methodology
while they are being treated at VA medical facilities. We reviewed these
assessments for all veterans who were registered sex offenders residing in
the residential programs or inpatient mental health units of our selected
medical facilities. To determine if registered sex offenders were residing at
the medical facilities we visited, we searched the Web sites of each
medical facility’s corresponding publicly available state sex offender
registry and included any individual registered under the address of the
selected medical facility’s residential programs or inpatient mental health
units in our sample. 10 The addresses used for these searches were provided
by each medical facility. Our corresponding sample included eight
veterans from three of the five medical facilities we visited. VA medical
facility staff provided biopsychosocial assessments for seven of these
veterans and noted that the eighth assessment was never completed by the
medical facility. We analyzed the contents of these seven veterans’
biopsychosocial assessments to determine the extent to which these
records contained information about these veterans’ current and past legal
issues, including documentation of convictions and parole or probation
status. We also reviewed information contained in these assessments
regarding these veterans’ histories of sexual abuse. Our review of veterans’
biopsychosocial assessments was limited to only those veterans meeting
these criteria and cannot be generalized to broader VA patient
populations.
Review of Selected VA
Medical Facilities’ Physical
Security Precautions
To examine the physical security precautions in place in residential
programs and inpatient mental health units, physical security experts from
our Forensic Audits and Investigative Services team conducted an
independent assessment of physical security measures in place at the
medical facilities we visited. To conduct this assessment, these experts
assessed the physical security precautions in place at each of the five
medical facilities we visited and identified any weaknesses they observed
in these systems using criteria based on generally recognized security
standards and selected VA security requirements. These reviews included
the testing of some physical security precautions, such as panic alarm
systems, and interviews with staff working in the residential programs and
inpatient mental health units that were reviewed. Our review of these
10
We conducted these searches prior to our arrival at each selected facility except for our
first site visit. Due to the pilot nature of this site visit, our initial search was insufficient for
this sample and was rerun at the completion of our field work. Veterans registered as sex
offenders as of the date of our second check of the state publicly available state sex
offender registry are included in our review of biopsychosocial assessments.
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GAO-11-530 Safety in VA Medical Facilities
Appendix I: Scope and Methodology
precautions was limited to only those medical facilities we reviewed and
does not represent results from all VA medical facilities nationwide.
We conducted our performance audit from May 2010 through June 2011 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives. We conducted our related investigative
work in accordance with standards prescribed by the Council of
Inspectors General on Integrity and Efficiency.
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GAO-11-530 Safety in VA Medical Facilities
Appendix II: Analysis of VA Police Reports of
Sexual Assault Incidents from January 2007
through July 2010
Appendix II: Analysis of VA Police Reports of
Sexual Assault Incidents from January 2007
through July 2010
This appendix provides additional results from our analysis of VA police
reports of sexual assault incidents from January 2007 through July 2010.
Cases not reported to the VA police are not included in our analysis of
sexual assault incidents.
•
Figure 3 shows the number of sexual assault incidents reported at VA
medical facilities to VA police by Veterans Integrated Service Network
(VISN) from January 2007 through July 2010. This count ranged from 34
incidents reported in VISNs C and D to no incidents reported in VISN E.
•
Table 6 shows the total number of sexual assault incidents alleging rape by
gender of the perpetrator and victim from January 2007 through July 2010.
•
Table 7 shows the total number of sexual assault incidents alleging rape by
the perpetrator and victim relationship to VA from January 2007 through
July 2010.
•
Table 8 shows the total number of patient-on-patient assault incidents and
patient-on-employee assault incidents by the type of sexual assault
incident from January 2007 through July 2010.
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GAO-11-530 Safety in VA Medical Facilities
Appendix II: Analysis of VA Police Reports of
Sexual Assault Incidents from January 2007
through July 2010
Figure 3: Number of Sexual Assault Incidents Reported to VA Medical Facility Police by VISN, January 2007 through July 2010
Number of sexual assault incidents reported to VA police at medical facilities
40
35
30
25
20
15
10
5
0
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
VISN
Sources: GAO (analysis); VA (data).
Notes: In this report, we use the term sexual assault incident to refer to suspected, alleged,
attempted, or confirmed cases of sexual assault. All reports of sexual assault incidents do not
necessarily lead to prosecution and conviction. This may be, for example, because an assault did not
actually take place or there was insufficient evidence to determine whether an assault occurred.
Complete analysis of 2007, 2008, and 2010 data was limited by three factors: (1) our analysis of 2007
VA police files was limited due to the requirement that VA police destroy investigative files after
3 years under a records schedule approved by the National Archives and Records Administration,
(2) our analysis of 2007 and 2008 VA police files was limited due to VA police manually submitting
these files to VA’s Office of Security and Law Enforcement (OSLE) for the purpose of this data
request because a centralized VA police reporting system did not exist prior to January 2009, and
(3) our analysis of 2010 records was limited to only those received by VA police through July 2010.
There are 21 VISNs in the VA health care system. VISNs 1-12 and VISNs 15-23. For reporting
purposes, VISN numbers were blinded to protect the anonymity of each individual VISN.
Cases not reported to VA police were not included in our analysis of sexual assault incidents.
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GAO-11-530 Safety in VA Medical Facilities
Appendix II: Analysis of VA Police Reports of
Sexual Assault Incidents from January 2007
through July 2010
Table 6: Total Sexual Assault Incidents Alleging Rape by Perpetrator and Victim
Gender, January 2007 through July 2010
Perpetrator/victim gender
Total sexual assault incidents involving rapea
Female/male
5
Male/female
31
Male/male
20
Unknown/female
8
Unknown/male
3
Total
67
Source: GAO (analysis); VA (data).
Notes: In this report, we use the term sexual assault incident to refer to suspected, alleged,
attempted, or confirmed cases of sexual assault. All reports of sexual assault incidents do not
necessarily lead to prosecution and conviction. This may be, for example, because an assault did not
actually take place or there was insufficient evidence to determine whether an assault occurred.
Complete analysis of 2007, 2008, and 2010 data was limited by three factors: (1) our analysis of 2007
VA police files was limited due to the requirement that VA police destroy investigative files after three
years under a records schedule approved by the National Archives and Records Administration,
(2) our analysis of 2007 and 2008 VA police files was limited due to VA police manually submitting
these files to VA’s OSLE for the purpose of this data request because a centralized VA police
reporting system did not exist prior to January 2009, and (3) our analysis of 2010 records was limited
to only those received by VA police through July 2010.
The rape category includes any case involving allegations of rape, defined as vaginal or anal
penetration through force, threat, or inability to consent. For cases that included allegations of
multiple categories including rape (i.e. inappropriate touch, forced oral sex, and rape) the category of
rape was applied. Cases where staff deemed that one or more of the veterans involved were mentally
incapable of consenting to sexual activities described in the case were considered rape.
a
Cases not reported to VA police are not included in our analysis of sexual assault incidents.
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GAO-11-530 Safety in VA Medical Facilities
Appendix II: Analysis of VA Police Reports of
Sexual Assault Incidents from January 2007
through July 2010
Table 7: Total Sexual Assault Incidents Alleging Rape by Perpetrator and Victim
Relationship to VA, January 2007 through July 2010
Perpetrator/victim
relationship to VA
Total sexual assault
incidents involving rapea
Employee/employee
2
Employee/outsider
1
Employee/patient
13
Employee/visitor
1
Outsider/employee
1
Outsider/outsider
2
Patient/employee
1
Patient/patient
25
Unknown/patient
19
Visitor/patient
2
Total
67
Source: GAO (analysis); VA (data).
Notes: In this report, we use the term sexual assault incident to refer to suspected, alleged,
attempted, or confirmed cases of sexual assault. All reports of sexual assault incidents do not
necessarily lead to prosecution and conviction. This may be, for example, because an assault did not
actually take place or there was insufficient evidence to determine whether an assault occurred.
Complete analysis of 2007, 2008, and 2010 data was limited by three factors: (1) our analysis of 2007
VA police files was limited due to the requirement that VA police destroy investigative files after three
years under a records schedule approved by the National Archives and Records Administration,
(2) our analysis of 2007 and 2008 VA police files was limited due to VA police manually submitting
these files to VA’s OSLE for the purpose of this data request because a centralized VA police
reporting system did not exist prior to January 2009, and (3) our analysis of 2010 records was limited
to only those received by VA police through July 2010.
The rape category includes any case involving allegations of rape, defined as vaginal or anal
penetration through force, threat, or inability to consent. For cases that included allegations of
multiple categories including rape (i.e. inappropriate touch, forced oral sex, and rape) the category of
rape was applied. Cases where staff deemed that one or more of the veterans involved were mentally
incapable of consenting to sexual activities described in the case were considered rape.
a
Cases not reported to VA police are not included in our analysis of sexual assault incidents.
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GAO-11-530 Safety in VA Medical Facilities
Appendix II: Analysis of VA Police Reports of
Sexual Assault Incidents from January 2007
through July 2010
Table 8: Patient-on-Patient Assault Incidents and Patient-on-Employee Assault Incidents by Type of Sexual Assault Incident,
January 2007 through July 2010
Inappropriate touchb
Forceful
medical examination
Forced or
inappropriate oral sex
25
54
0
8
2
89
1
83
0
1
0
85
26
137
0
9
2
174
Rapea
Patient-on-patient
Patient-on-employee
Total
c
Other
Totald
Source: GAO (analysis); VA (data).
Notes: In this report, we use the term sexual assault incident to refer to suspected, alleged,
attempted, or confirmed cases of sexual assault. All reports of sexual assault incidents do not
necessarily lead to prosecution and conviction. This may be, for example, because an assault did not
actually take place or there was insufficient evidence to determine whether an assault occurred.
Complete analysis of 2007, 2008, and 2010 data was limited by three factors: (1) our analysis of 2007
VA police files was limited due to the requirement that VA police destroy investigative files after three
years under a records schedule approved by the National Archives and Records Administration,
(2) our analysis of 2007 and 2008 VA police files was limited due to VA police manually submitting
these files to VA’s OSLE for the purpose of this data request because a centralized VA police
reporting system did not exist prior to January 2009, and (3) our analysis of 2010 records was limited
to only those received by VA police through July 2010.
a
The rape category includes any case involving allegations of rape, defined as vaginal or anal
penetration through force, threat, or inability to consent. For cases that included allegations of
multiple categories including rape (i.e. inappropriate touch, forced oral sex, and rape) the category of
rape was applied. Cases where staff deemed that one or more of the veterans involved were mentally
incapable of consenting to sexual activities described in the case were considered rape.
b
The inappropriate touch category includes any case involving only allegations of touching, fondling,
grabbing, brushing, kissing, rubbing, or other like-terms.
c
The other category included any allegations that did not fit into the other categories or if the incident
described in the case file did not contain sufficient information to place the case in one of the other
designated categories.
d
Cases not reported to VA police are not included in our analysis of sexual assault incidents.
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GAO-11-530 Safety in VA Medical Facilities
Appendix III: Comments from the Department
of Veterans Affairs
Appendix III: Comments from the
Department of Veterans Affairs
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Appendix III: Comments from the Department
of Veterans Affairs
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GAO-11-530 Safety in VA Medical Facilities
Appendix III: Comments from the Department
of Veterans Affairs
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Appendix III: Comments from the Department
of Veterans Affairs
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GAO-11-530 Safety in VA Medical Facilities
Appendix III: Comments from the Department
of Veterans Affairs
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GAO-11-530 Safety in VA Medical Facilities
Appendix III: Comments from the Department
of Veterans Affairs
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GAO-11-530 Safety in VA Medical Facilities
Appendix III: Comments from the Department
of Veterans Affairs
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GAO-11-530 Safety in VA Medical Facilities
Appendix III: Comments from the Department
of Veterans Affairs
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GAO-11-530 Safety in VA Medical Facilities
Appendix III: Comments from the Department
of Veterans Affairs
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Appendix III: Comments from the Department
of Veterans Affairs
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GAO-11-530 Safety in VA Medical Facilities
Appendix IV: GAO Contact and Staff
Acknowledgments
Appendix IV: GAO Contact and Staff
Acknowledgments
GAO Contact
Randall B. Williamson, (202) 512-7114 or [email protected]
Staff
Acknowledgments
In addition to the contact named above, Marcia A. Mann, Assistant
Director; Gary A. Bianchi; Robin Burke; Emily Goodman; Katherine
Nicole Laubacher; Lisa Motley; Andy O’Connell; George Ogilvie;
Carmen Rivera-Lowitt; and Cassandra Yarbrough made key
contributions to this report.
(290846)
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GAO-11-530 Safety in VA Medical Facilities
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